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Bladder

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Bladder cancer

Diagnosis

Treatments

Bladder cancer is responsible for approximately 3% of all malignancies diagnosed in
Australia each year. Bladder cancer is more common in men than women and typically
affects people over 60 years of age.

Bladder cancer that is at an early stage of growth may not produce any noticeable signs
or symptoms. Common signs of bladder cancer include haematuria (bloody urine that looks
red or rusty), which is usually painless and may appear only from time to time over a
period of months, a burning sensation during urination and a need to urinate often.
It is important to note that these symptoms can also be characteristic of urinary tract infection.

When bladder cancer causes noticeable symptoms, these symptoms are usually related
to the irritation brought about by tumour growth. Irritable symptoms include urination
that is frequent, urgent, painful or difficult. These symptoms are more common among
patients with ‘carcinoma in situ’ (CIS), cancer that has not spread and is still "in place".
In fact, irritable urination (emptying of the bladder) may be the only noticeable symptom
of CIS. Since irritable such symptoms also are caused by bacterial infections and kidney
stones, it is essential to see your doctor to make an accurate diagnosis. A qualified doctor
should evaluate any symptoms that last longer than 2 weeks.

If a bladder tumour blocks a ureter (one of the two tubes that pass urine out of the kidneys
and into the bladder), patients may experience pain in the side of the body between the
ribs and the top of the hip. In some cases, tumour growth may constrict the urethra (the
tube that passes urine from the bladder out of the body) and slow the flow of the urine
stream. Bladder cancers may also shed pieces of dead tissue, fragments of other tissue
and other forms of tumour related matter that are then passed out with the urine.

If the tumour has spread beyond the bladder to surrounding tissue, the patient may
experience pelvic pain. In addition, metastases from a bladder cancer may cause secondary symptoms, such as bone pain at the site of the new cancer or leg swelling (oedema) due to
the involvement of the lymph nodes. Bladder cancer that has progressed to the point of organ invasion and metastases may eventually cause the patient to lose weight and feel fatigued. Anaemia and high blood levels of urea and other metabolic by-products, often due to urinary
tract obstruction, may be further indications of late-stage bladder cancer.


Diagnosis

If there is blood in the urine, or any of the other symptoms mentioned are experienced,
your doctor will need to conduct some physical examinations in order to formulate an
accurate diagnosis.


Cystoscopy

During a cystoscopy a thin flexible tube with a light and a camera lens is inserted into the
urethra and up into the bladder, allowing the doctor to look at the inner lining of the bladder
and check for any abnormalities or suspicious looking tissue. The doctor may also take a
biopsy that can be examined more closely in a laboratory allowing an accurate diagnosis
to be made.

Intravenous Pyelogram (IVP)

A special dye is injected your arm that travels through the bloodstream to the urinary tract,
which in turn is then picked up through an x-ray. This process allows a doctor to see if there
are any abnormalities in the bladder or urinary tract.



Treatments

There are a number of possible treatments available to patients diagnosed with bladder
cancer. These include Chemotherapy (see chemo information), Radiation Therapy and
Surgery. A number of treatments may be used in conjunction with each other, typical
examples being the use of pre-operative Radiation Therapy to shrink the tumour or slow
its growth, or Intra-vesical therapies such as systemic chemotherapy.

The choice of treatments depend on a number of factors, including your age, general health
and the extent and stage of the tumour. Discuss this with your doctor to ascertain the most appropriate course of treatment for you.

Surgery

Bladder cancers that have grown into surrounding tissue usually require surgical therapy.
Tumors that have invaded the muscle or tissue around the bladder need surgical
management.

Radical Cystectomy

For women, a standard form of surgery is a Radical Cystectomy, which involves cutting
away the entire bladder and associated tissues, with Pelvic Lymphadenectomy (removal
of the lymph nodes within the hip cavity).. Radical cystectomy in women includes removal
of the uterus, Fallopian tubes, ovaries, anterior vaginal wall (the front of the birth canal),
and urethra.

In men, a common surgical procedure is called a Cysto-Prostatectomy, which involves the removal of the bladder and prostate, with Pelvic Lymphadenectomy

Trans Urethral Resection of the Bladder Tumour (TURBT)

This procedure involves the inserting a thin tube, through the urethra and up into the bladder.
The surgeon can then remove the tumour without the need for a large external excision



Urinary Diversion

The body regulate its internal chemistry by passing blood through the kidneys, which then
filter the blood and passing the wasted through the ureters into the bladder. This wasted is
then discharged from the body in the form of urine.

Because some types of cancer can only be remedied by removing the bladder, another way
must be found in order for the body to discharge urine. These procedures are called urinary diversions.

The most common diversion is called an Ileal Conduit – this involves taking a piece of bowel
and forming a ‘pipe’ that is inserted where the bladder once was. The conduit then carries the urine from the ureters out onto the skin of the abdomen where the conduit ends in a Stoma –
a small opening. Urine is then emptied into a plastic bag attached to the skin, where it can be emptied at various intervals.

Other forms of diversion involve the formation of an internal pouch made out of part of the
bowel. The pouch has an inbuilt valve so that urine collects inside and does not leak through
the Stoma. When it needs emptying, a small plastic tube called a Catheter can be passed
through the stoma and the valve allowing urine to flow out. This is a major piece of surgery
and requires much planning and recuperation time. The suitability of this procedure should
be discussed with the Urologist.


Intra-vesical treatment

Intra-vesical treatment involves flushing the bladder with chemotherapy or immunotherapy
to flush out any residual tumour cells following surgery. Chemotherapy drugs are placed
directly into the bladder in order to prevent the tumour recurring or to prevent it from
invading the deeper layers of the bladder wall. Researchers have trialled various
combinations of systemic drugs and a number of these have proven efficacy in the
adjuvant treatment of bladder cancers.


Radiation Therapy for Bladder Cancer

What is Radiation Therapy?

Radiation therapy uses powerful x-rays and other high-energy rays to kill cancer cells
using a machine called a ‘Linear Accelerator’. Damaging the cancer cells means that they
cannot grow
or multiply and so they die. Normal cells are also damaged in this procedure but usually
recover.

Who gets Radiation Therapy?

A number of tests will be performed in order to allow doctors to determine the best
course of treatment for each individual. The tests include a cystoscopy and a CT scan.
These will show doctors the size of the tumour present and help determine whether
radiation therapy is solely used or whether it can be used in conjunction with other
treatments.

Before having radiation therapy a number of initial procedures need to be performed
allowing doctors to specifically plan the best treatments for the type of cancer and the
individual involved. This means that an accurate radiation dose to your cancer can be
calculated while limiting the radiation to the surrounding areas such as the rectum.

CT Scan

CT scans are special x-rays that show the internal organs of your body. Dyes may
also be injected allowing the doctor to see the area more clearly.

Planning

During treatment planning the radiation oncologist uses all the information gathered to
develop
an individual treatment plan.

What are the Side Effects?

The x-rays used during radiation therapy may damage normal body cells as well as
cancer cells, although healthy cells usually recover from the damage. The incidence and
severity of any side effects vary from patient to patient and may include:

Tiredness or fatigue

Bladder irritation, cramps or painful urination/blood in the urine

Diarrhoea and Bowel Cramps

Proctitis or pain in the rectum/bleeding

Vaginal discomfort

A variety of measures can be taken to alleviate these symptoms, discuss these issues with
your doctor and radiation therapy team for the best advice for each individual.