MEDICAL CONDITIONS
Bladder Cancer
What is the bladder?
The bladder is a hollow organ in the lower abdomen that stores urine. The kidneys filter waste from the blood and produce urine, which enters the bladder through two tubes called ureters. Urine leaves the bladder through another tube, the urethra. In women, the urethra is a short tube that opens just in front of the vagina. In men, it is longer, passing through the prostate gland and then the penis. 
What is bladder cancer?
Cancer is a group of diseases. More than 100 different types of cancer are known, and there are different types of bladder cancer. They all have one thing in common: abnormal cells grow and destroy body tissue.
Healthy cells that make up the body's tissues grow, divide, and replace themselves in an orderly way. This process keeps the body in good repair. Sometimes, however, some cells lose the ability to control their growth. They grow too rapidly and without any order. Too much tissue is made, and tumors begin to form. Tumors can be benign or malignant.
Benign tumors are not cancer. They do not spread to other parts of the body and are seldom a threat to life. Often, benign tumors can be removed by surgery, and they are not likely to return.
Malignant tumors are cancer. They can invade and destroy nearby healthy tissues and organs. Cancer cells can also break away from the tumor and enter the bloodstream and lymphatic system. That is how cancer can spread to other parts of the body. This spread is called metastasis. Even if cancer is removed from the bladder, the disease sometimes returns, because cancer cells may have already spread.
Most bladder cancers develop in the inside lining of the bladder. The cancer often looks like a small mushroom attached to the bladder wall. It may also be called a papillary tumor. Often, more than one tumor is present.
Bladder cancer is a fairly common form of cancer in the United States. Whites contract bladder cancer twice as often as blacks, and men are affected two to three times as often as women. Most bladder cancers occur after the age of 55, but the disease can also develop in younger people.
What are the risk factors for bladder cancer?
While it is unknown why one person gets bladder cancer and another doesn't, it is established. that the disease is not contagious. No one can "catch" bladder cancer from another person. Scientists do not know exactly what causes this disease, but research does show that some people are more likely to develop it than others. A number of factors contribute to this higher risk.
Smoking is a major risk factor. Cigarette smokers develop bladder cancer two to three times more often than do nonsmokers. Quitting smoking reduces the risk of bladder cancer, lung cancer , several other types of cancer, and a number of other diseases as well.
Workers in some occupations are at higher risk of developing bladder cancer because of exposure to carcinogens (cancer- causing substances) in the workplace. These workers include people in the rubber, chemical, and leather industries, as well as hairstylists, machinists, metal workers, printers, painters, textile workers, and truck drivers.
What are the symptoms of bladder cancer?
The most common warning sign of bladder cancer is blood in the urine. Depending on the amount of blood present, the color of the urine can range from faintly rusty to deep red. Pain during urination can also be a sign of bladder cancer. A need to urinate often or urgently may be another warning sign. Often, bladder tumors cause no symptoms.
When symptoms do occur, they are not sure signs of cancer. They may also be caused by infections, benign tumors, bladder stones, or other problems. It is important to see a doctor to determine the cause of the symptoms. Any illness should be diagnosed and treated as early as possible.
How is bladder cancer diagnosed?
To diagnose bladder cancer, a personal and family medical history is taken and a thorough physical examination is conducted. Sometimes, the doctor can feel a large tumor during a rectal or vaginal exam. In addition, urine samples are checked under the microscope to see whether any cancer cells are present.
Often, the doctor orders an x-ray called an intravenous pyelogram (IVP). This test allows the doctor see the kidneys, ureters, and bladder on an x-ray. An IVP normally causes little discomfort, although a few patients experience nausea, dizziness, or pain from the procedure.
The doctor may also look directly into the bladder with an instrument called a cystoscope. In this test, a thin, lighted tube is inserted into the bladder through the urethra. If the doctor sees any abnormal areas, samples of tissue can be removed through the cystoscope. This is called a biopsy. A pathologist examines the tissue under a microscope to see whether cancer cells are present. A biopsy is needed to make a definite diagnosis of bladder cancer.
What is the treatment for bladder cancer?
Treatment for bladder cancer depends on a number of factors. Among these are how quickly the cancer is growing; the number, size, and location of the tumors; whether the cancer has spread to other organs; and the patient's age and general health.
Staging
Before treatment begins, it is important to know exactly where the cancer is located and whether it has spread from its original location. Staging procedures include a complete physical exam and additional blood tests and scans.
A CT (or CAT) scan may be performed. A CT scan is a series of x-rays put together by a computer to form a detailed picture. Ultrasound is a procedure that creates pictures of the inside of the body using high-frequency sound waves. The echoes make an image on a video screen that is much like a television. Sometimes, a magnetic resonance imaging (MRI) is performed, in which a cross-sectional image (like a CT scan) is produced on a screen with the use of a powerful magnet instead of x-rays.
Methods of Treatment
Early (superficial) bladder cancer (in which the tumors are found on the surface of the bladder wall) generally can be treated using the cystoscope in a procedure called transurethral resection (TUR). The cystoscope can remove all or part of a tumor or destroy it with an electric current.
When several tumors are present in the bladder or when there is a risk that the cancer will recur, TUR may be followed by treatment with drugs. The doctor may put a solution containing the bacillus Calmette-Guerin (BCG), a form of biological therapy , directly into the bladder. Chemotherapy (anticancer drugs) may also be inserted directly into the bladder.
Radiation therapy (also called radiotherapy) may be needed when the cancer cannot be removed with TUR because it involves a larger area of the bladder. X-rays destroy the ability of cancer cells to grow and divide. Internal radiation therapy, with the radioactive material placed in the bladder, may be combined with external radiation, which comes from a machine located outside the body.
For internal radiation therapy, radioactive material is inserted into the bladder through the cystoscope. This puts cancer-killing rays as close as possible to the site of the cancer while sparing most of the healthy tissues around it. The patient is hospitalized for this treatment for approximately 4 to 7 days.
For external radiation treatments, the patient goes to the hospital or clinic each day. Usually, treatments are given 5 days a week for 5 to 6 weeks. This schedule helps to protect normal tissue by spreading out the total dose of radiation.
When the cancer involves much of the surface of the bladder or has grown into the bladder wall, standard treatment is to remove the entire bladder. This surgery is called a radical cystectomy. In this operation, the surgeon removes the bladder as well as nearby organs. In women, this operation includes removing the uterus, fallopian tubes, ovaries, and part of the vagina. In men, the prostate and seminal vesicles are removed. Research is under way to find treatments that spare the bladder.
When cancer involves the pelvis or has spread to other parts of the body, the doctor may suggest chemotherapy, the use of anticancer drugs that travel through the bloodstream to reach cancer cells in all parts of the body. Drugs used to treat cancer are either given by mouth or injected into a muscle or a blood vessel. Chemotherapy is usually given in cycles, a treatment period, followed by a rest period, then another treatment period, and so on.
The patient usually receives chemotherapy as an outpatient at the hospital, at the doctor's office, or at home. Sometimes, the patient may need to stay in the hospital for a short while.
What are the side effects of bladder cancer treatment?
The methods used to treat bladder cancer are very powerful. It is hard to limit the effects of treatment so that only cancer cells are destroyed; healthy tissue may also be damaged. That is why treatment can cause unpleasant side effects. Side effects depend on the type of treatment used and on the part of the body being treated.
When the bladder is removed, the patient needs a new way to store and pass urine. Various methods are used. In one, the surgeon uses a piece of the person's small intestine to form a new pipeline. The ureters are attached to one end, and the other end is brought out through an opening in the wall of the abdomen. This new opening is called a stoma. (It is also called an ostomy or urostomy.) A flat bag fits over the stoma to collect urine, and it is held in place with a special adhesive. A specially trained nurse or enterostomal therapist will show the patient how to care for the ostomy.
A newer method uses part of the small intestine to make a new storage pouch (called a continent reservoir) inside the body. The urine collects there and does not empty into a bag. Instead, the patient learns to use a tube (catheter) to drain the urine through a stoma. Other methods are being developed that connect a pouch made from the small intestine to a remaining part of the urethra. When this procedure is possible, a stoma and bag are not necessary because urine leaves the body through the urethra.
Radical cystectomy causes infertility in both men and women. This operation can also lead to sexual problems. In the past, nearly all men were impotent following this procedure, but improvements in surgery have made it possible to prevent this in many men. In women, the vagina may be narrower or shallower, and intercourse may be difficult.
During radiation therapy, patients may become very tired as the treatment continues. Resting as much as possible is important. Radiation treatment to the lower abdomen may cause nausea, vomiting, or diarrhea . Usually, certain foods or medications can ease these problems. Radiation therapy can also cause problems with fertility and can make sexual intercourse uncomfortable.
Chemotherapy causes side effects because it damages not only cancer cells but other rapidly growing cells as well. The side effects of chemotherapy depend on the specific drugs that are given. In addition, each patient reacts differently. Chemotherapy commonly affects blood-forming cells and cells that line the digestive tract. As a result, patients may have side effects such as a lowered resistance to infection, loss of appetite, loss of hair, nausea and vomiting, less energy, and mouth sores. These are short-term side effects that usually end after treatment stops. When drugs are put directly into the bladder, these side effects may be limited. However, it is common for the bladder to be irritated.
Loss of appetite can be a serious problem for patients during therapy. Patients who eat well may be better able to withstand the side effects of their treatment, so good nutrition is an important part of the treatment plan. Eating well means getting enough calories to prevent weight loss and having enough protein to build and repair muscles, organs, skin, and hair. Many patients find that eating several small meals and snacks during the day is easier than trying to eat three large meals.
Side effects during cancer treatment vary for each patient. They may even be different from one treatment to the next in the same person. Attempts are made to plan treatment to minimize problems. Fortunately, most side effects are temporary. Doctors, nurses, and dietitians can explain the side effects of cancer treatment and can suggest ways to deal with them.
What happens after treatment for bladder cancer?
Regular follow-up exams are very important after treatment for bladder cancer. The bladder needs to be checked with a cystoscope, any superficial tumors that may have recurred are removed. The urine is checked for cancerous cells and a chest x-ray, an IVP, or other tests may be performed.
A patient who has had bladder cancer should be closely monitored for several years, because bladder tumors can come back. If the cancer does recur, early detection is important so that additional treatment can be started.
How can patients cope with bladder cancer?
The diagnosis of bladder cancer can change the lives of cancer patients and the people who care about them. These changes in daily life can be difficult to handle. It is natural for patients and their families and friends to have many different and sometimes confusing emotions.
Patients and their loved ones may feel frightened, angry, or depressed. These are normal reactions that people have when diagnosed with a serious health problem. Others in the same situation have found that they cope with their emotions better if they can talk openly about their illness and their feelings with those who care about them.
Concerns about what the future may hold, as well as worries about tests, treatments, hospital stays, and medical bills, are common. Talking with doctors, nurses, or other members of the health care team may help to calm fears and ease confusion. Patients can take an active part in decisions about their medical care by asking questions about bladder cancer and their treatment choices. Patients, family, or friends often find it helpful to write down questions to ask the doctor as they think of them. Taking notes during visits to the doctor helps them remember what was said. Patients should ask the doctor to explain anything that is not clear.
Patients have many important questions, and the doctor is the best person to answer them. Most people ask about the extent of their cancer, how it can be treated, and how successful the treatment is likely to be. The doctor is the best person to give advice about treatment, working, or limiting daily activities. Patients may also wish to discuss concerns about the future, family relationships, and finances. They may find it helpful to speak with a nurse, social worker, counselor, or a member of the clergy.
Sharing feelings with loved ones can help everyone feel more at ease, opening the way for others to show their concern and offer their support. Many patients feel that it helps to talk with others who are facing problems like theirs. Patients can meet other cancer patients through self-help and support groups such as those described in the next section.
What support can bladder cancer patients seek?
Learning to live with the changes brought about by having cancer is easier for patients and those who care about them when they have helpful information and support services. Often, the social worker at the hospital or clinic can suggest local and national groups that will help with emotional support, financial aid, transportation, home care, and rehabilitation.
If a patient has problems with a urostomy, the doctor, nurse, or enterostomal therapist can help. Adjusting to a stoma can be a lot easier with the advice and support of someone who has had the same problem. Many people have had bladder surgery, and several organizations offer assistance.
The Ostomy Rehabilitation Program of the American Cancer Society (ACS) and the United Ostomy Association (UOA) offer both emotional support and educational material. Information is available from local chapters (listed in the telephone book) or from the ACS and UOA national offices, whose addressed and telephone numbers are listed below.
What does the future hold for bladder cancer?
Each year, more than 50,000 people in the United States find out they have bladder cancer. The outlook for patients with early bladder cancer is very good. The chances of recovery from more advanced bladder cancer are improving as researchers continue to look for better ways to treat this disease.
Doctors often talk about "surviving" cancer, or they may use the word "remission" rather than "cure." Even though many bladder cancer patients recover completely, doctors use these terms because bladder cancer can recur. It is normal for patients to be concerned about their future. Sometimes they use statistics they have heard to try to figure out their chance of being cured. It is important to remember, however, that statistics are averages. They are based on the experiences of large numbers of patients, and no two cancer patients are alike. Only the doctor who takes care of the patient knows enough about his or her case to discuss the patient's chance of recovery (prognosis).
Scientists at hospitals and medical centers all across the country are studying bladder cancer. They are trying to learn what causes the disease and how to prevent it. They are also looking for better ways to diagnose and treat it.
The National Cancer Institute is supporting many studies of new treatments for bladder cancer. When laboratory research shows that a new treatment method has promise, it is used to treat cancer patients in clinical trials. These trials are designed to answer scientific questions and to find out if a new treatment is both safe and effective. Patients who take part in clinical trials make an important contribution to medical science and may have the first chance to benefit from improved treatment methods. - While the exact cause(s) of bladder cancer is not known, risk factors have been identified.
- The most common warning sign of bladder cancer is blood in the urine.
- The diagnosis of bladder cancer is supported by findings of the medical history and examination, blood, urine, and x-ray tests, and confirmed with a biopsy (usually during a cystoscope exam).
- Treatment of bladder cancer depends on the growth, size, and location of the tumor as well as the age and health of the patient.
RESOURCES
Information about cancer is available from many sources, including the ones listed below. You may wish to check for additional information at your local library or bookstore and from support groups in your community.
CANCER INFORMATION SERVICE (CIS)
1-800-4-CANCER
The Cancer Information Service, a program of the National Cancer Institute, provides a nationwide telephone service for cancer patients and their families and friends, the public, and health professionals. The staff can answer questions and can send booklets about cancer. They also know about local resources and services. One toll-free number, 1-800-4-CANCER (1-800-422-6237), connects callers all over the country to the office that serves their area. Spanish-speaking staff members are available.
AMERICAN CANCER SOCIETY (ACS)
1599 Clifton Road, N.E.
Atlanta, GA 30329
1-800-ACS-2345
The American Cancer Society is a voluntary organization with a national office (at the above address) and local units all over the country. It supports research, conducts educational programs, and offers many services to patients and their families. It provides free booklets on cancer and on sexuality. To obtain booklets or to learn about services and activities in local areas, call the Society's toll-free number, 1-800-ACS-2345 (1-800-227-2345), or the number listed under "American Cancer Society" in the white pages of the telephone book.
UNITED OSTOMY ASSOCIATION (UOA)
Suite 120
36 Executive Park
Irvine, CA 92714
714-660-8624
The United Ostomy Association is another organization with chapters in many cities. It offers a number of booklets for people with ostomies. In addition, volunteers will visit a patient to offer support and encouragement. The national office can provide the address of the nearest chapter.
Portions of the article presented here were reproduced with the kind permission of the National Institutes of Health ( http://www.nih.gov/ ).
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