The bladder is a hollow organ that stores urine. Urine flows into the bladder from the kidneys, where it is made, through thin tubes called ureters. Urine empties from the bladder through another tube called the urethra. In women the urethra is very short. In men it is longer since it passes through the prostate gland to the tip of the penis.
The wall of the bladder has several layers. Cancer begins in the lining layer and grows into the bladder wall. As the cancer grows deeper into the layers of the wall of the bladder, it becomes harder to treat.
The inside of the bladder is lined with a layer of cells called urothelial cells. The same type of cells also lines the kidneys, the tubes connecting the kidneys to the bladder (ureters), and the urethra. Cancer can begin in the lining cells in any of these structures which are part of the urinary system.
Types of Bladder Cancer
There are 4 main types of bladder cancer. They are grouped by the way the cancer cells look under a microscope.
Urothelial carcinoma: This is by far the most common type of bladder cancer. It starts in the urothelial cells. It is also called transitional cell carcinoma. Within this group are also several subtypes. They are named depending on the shape of the cells and whether they tend to spread and invade other organs (invasive).
Squamous cell carcinoma: This type is much less common and is usually invasive.
Adenocarcinoma: This type is also much less common and almost all are invasive.
Small cell: A very small number of bladder cancers are of this type.
These 4 types of bladder cancer respond to treatment in different ways. For some people, the type of treatment they get can be influenced by the exact type of bladder cancer they have.
While there are other types of bladder cancer, they are very rare. There are also a number of bladder tumors that are benign (not cancer). Ask your doctor to explain to you exactly what type of tumor you have and what it means in your case.What Causes Bladder Cancer?
We do not yet know exactly what causes bladder cancer, but we do know that certain risk factors are linked to the disease. A risk factor is anything that increases a person's chance of getting a disease such as cancer. Different cancers have different risk factors. Some risk factors, such as smoking, can be controlled. Others, like a person's age or family history, can't be changed. But having a risk factor, or even several, doesn�t mean that a person will get the disease.
The following risk factors have been linked to bladder cancer:
Smoking: Smoking is the greatest risk factor for bladder cancer. Smokers get bladder cancer twice as often as people who don't smoke. Certain chemicals in tobacco smoke are absorbed from the lungs and get into the blood. From the blood, they are filtered by the kidneys and collect in the urine. These chemicals in the urine damage the cells that line the inside of the bladder and increase the risk of cancer.
Work exposure: Some chemicals used in the making of dye have been linked to bladder cancer. Other types of industries use chemicals that may put workers at risk if good safety practices are not followed. Workers with a higher risk of bladder cancer include painters, hairdressers, machinists, printers, and truck drivers. Smoking can increase the risk among these workers. People who work with chemicals called aromatic amines may have higher risk. These chemicals are used in making rubber, leather, printing materials, textiles, and paint products.
Race: Whites are twice as likely to develop bladder cancer as are African Americans and Hispanics. Asians have the lowest rate of bladder cancer.
Age: The risk of bladder cancer goes up with age.
Gender: Men get bladder cancer 4 times as often as women.
Chronic bladder inflammation: While urinary infections, kidney stones, and bladder stones don�t cause bladder cancer, they have been linked to it.
Personal or family history of bladder cancer: People who have had bladder cancer have a higher chance of getting another tumor. People whose family members have had bladder cancer also have a higher risk.
Bladder birth defects: Very rarely a connection between the belly button and the bladder doesn�t disappear as it should before birth and can become cancerous. There is another, very rare, birth defect called exstrophy which can lead to bladder cancer.
Earlier treatment: Some drugs or radiation used to treat other cancers can increase the risk of bladder cancer.
Arsenic: Arsenic in drinking water has been linked to a higher risk of bladder cancer.
Not drinking enough liquids: People who drink lots of liquids each day have a lower rate of bladder cancer.How Is Bladder Cancer Found?
Bladder cancer can sometimes be found early. Finding it early improves the chances that it can be treated successfully.
Screening tests are used to look for a disease in people who have not had that disease before and do not have any symptoms. Unless you have strong risk factors, screening tests for bladder cancer are not recommended. Such risk factors would include having had bladder cancer in the past, certain defects of the bladder, and perhaps working with certain chemicals. If you are at high risk of bladder cancer, your doctor might suggest certain tests such as urine cytology or cystoscopy. These tests are explained below.
Signs and Symptoms of Bladder Cancer
Blood in the urine or changes in bladder habits: These can be signs of bladder cancer. Other signs might include having to urinate more often, or feeling as if you need to go but not being able to do so. Although these problems can be caused by something other than cancer, do not ignore them. Be sure to talk to your doctor if you have any of these symptoms.
If there is a reason to suspect you might have bladder cancer, the doctor will use one or more of the methods below to find out if the disease is really there.
Medical history and physical exam: First your doctor will ask you about your medical history to check for risk factors and symptoms. The doctor might check the rectum and vagina (in women) to see how big the tumor is and how far it may have spread.
Cystoscopy (sis-toss-kuh-pee): A cystoscope (sis-tuh-scope) is a thin tube with a lens and a light. The doctor places it into the bladder through the urethra. The area is first numbed or drugs may be used to put you into a deep sleep. With the cystoscope the doctor can see the inside of the bladder. If there is anything suspicious, a small piece of tissue is removed and looked at under a microscope (a biopsy).
Urine cytology: In this test, urine or cells "washed" from the bladder are sent to the lab to see if cancer cells (or pre-cancer cells) are present. This is often done at the same time as the cystoscopy.
Urine culture: A sample of your urine is sent to the lab to see if you might have an infection. An infection can sometimes cause symptoms like those of bladder cancer. It may take 2 or 3 days to get the results of this test.
Biopsy: A sample of any suspicious tissue is removed during cystoscopy and looked at under a microscope. This test can tell if cancer is present, what type of bladder cancer it is, and how deep it has gone into the bladder wall. Bladder cancers are graded on a scale from 1 to 4 based on how they look under the microscope. The lower the number, the more the cells look like normal tissue. A higher grade means the cancer is more likely to have spread outside the bladder and the outlook is not as good.
Bladder tumor marker studies: These tests look for certain substances released by cancer cells into the urine. Some doctors use these tests, but most think that more research is needed to see how useful they are.
Imaging tests: Imaging tests are done to allow your doctor to "see" your bladder and other organs. A number of these tests, such as IVP (intravenous pyelogram), CT scans, MRI scans, x-rays, ultrasound, and bone scans may be done to give the doctor more information about the cancer and whether it has spread. Feel free to ask your doctor about any tests that you will have.How Is Bladder Cancer Treated?
This information represents the views of the doctors and nurses serving on the American Cancer Society's Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.
The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.
Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don't hesitate to ask him or her questions about your treatment options.
There is a lot for you to think about when choosing the best way to treat or manage your cancer. There may be more than one treatment to choose from. You may feel that you need to make a decision quickly. But give yourself time to absorb the information you have learned. Talk to your doctor. Look at the list of questions in the section What Are Some Questions I Can Ask My Doctor? to get some ideas. Then add your own.
You may want to get a second opinion about the best treatment option for you. Doing so can give you more information and help you feel better about the treatment plan you choose. You will want to weigh the benefits of each treatment against side effects and risks.
The main types of treatment for bladder cancer are surgery, radiation therapy, immunotherapy, and chemotherapy. Based on the stage of your cancer, your doctor may recommend 1 or more of these. Surgery, alone or along with other treatments, is used in more than 9 out of 10 cases.
Surgery
There are several kinds of surgery for bladder cancer. Some involve removing the entire bladder and others do not. The type of surgery will depend on the stage of the cancer. The most common types of surgery are explained below.
Transurethral (trans-your-reeth-ruhl) surgery:This operation is used most often for early stage bladder cancer. It is done through a slender tube with a lens and a light that is placed into the bladder through the urethra. This tube is called a resectoscope (ree-sec-tuh-scope). You will have either medicine to make the area numb or be put into a deep sleep (general anesthesia). With this approach there is no need to cut into the abdomen. After surgery, there may be other steps to get rid of any remaining cancer. These steps could include burning the base of the tumor using a cystoscope or treatment with a laser.
The side effects of this surgery are often mild and do not usually last long. There may be some bleeding or mild pain right after surgery. You can usually go home the same day or the next day. In less than 1 to 2 weeks you should be able to do your normal activities. If this surgery has to be done several times long-term side effects may become a problem. There is a chance that the bladder can become scarred and not able to hold much urine. This means having to urinate often and the chance of losing urine (incontinence).
Cystectomy (sis-tek-tuh-me): This surgery is used when the bladder cancer is invasive (cancer that has spread beyond the layer of cells where it started to nearby tissues.) In this case the surgeon has to cut through the abdomen to get to the bladder. When only part of the bladder is removed, it is called a partial cystectomy. If the entire bladder is removed it is a radical cystectomy.
If the entire bladder is removed, nearby lymph nodes are also removed. In men, the prostate is removed as well. In women, the womb (uterus), ovaries, fallopian tubes, and a small part of the vagina are often removed too.
For either operation, you will be asleep. You will need to stay in the hospital for about 7 to 10 days. After about 4 to 6 weeks you should be able to go back to your normal activities. It is important that the surgeon doing this operation have experience in treating bladder cancer. If the surgery is not done well, the cancer is more likely to come back.
Side effects of this surgery could include a lot of bleeding, urinary infections, urine leakage, and blockage of urine flow.
Reconstructive surgery
If the whole bladder is removed, another way to store and remove urine from the body is needed. There are several ways to do this. These options can have a strong effect on how you feel about your body. You should talk to your doctors and nurses about any worries or concerns you might have when making these decisions. One option is a urostomy (your-os-tuh-me). In this approach, tissue taken from the small intestine (bowel) is attached to the ureters and connected to the skin of your belly though a small opening (stoma). A bag is attached to your belly over this opening to catch the urine.
A second method is called a continent diversion. This does not require a bag outside the body. Instead, the surgeon creates a sac from a small piece of intestine and attaches the ureters to it. Urine is emptied when the person places a drainage tube (catheter) into the hole of the diversion. Newer methods of surgery can route the urine into the urethra, making urination nearly normal.
Some problems from these methods could include wound infections, urine leaks, pouch stones, and blockage of urine flow.
Bladder Cancer Surgery and Sex
After radical bladder surgery, a man no longer makes semen. Sperm cells are still made but they are simply reabsorbed with no ill effects. After this surgery a man will have a "dry" orgasm, without semen.
There can be some nerve damage after this surgery that may cause men to become impotent�that is, unable to have an erection. Newer types of surgery may lower the chances of impotence and it may also go away over time. Generally, the younger a man is, the more likely he is to regain full erections. For more information about dealing with sexual issues, please see Sexuality and Cancer: For the Man Who Has Cancer and His Partner, available through our toll-free number or on our Web site.
It is normal for you to have concerns about your sex life after having a surgery for bladder cancer. With some simple planning, sex can be pleasurable and less stressful. Having a correct fit for your urostomy bag (if you have one) and emptying it before sex reduces the chances of a major leak. You might wear a pouch cover or t-shirt during sex. To reduce rubbing against the bag, choose positions that keep your partner�s weight off of it. For more information about dealing with a urostomy, please see Urostomy: A Guide.
Intravesical Immunotherapy
Intravesical (in-truh-ves-uh-cul) treatment is placed directly into the bladder rather than being given by mouth or injected into a vein. The most common form of this type of treatment for bladder cancer is immunotherapy. This method causes the body�s own natural defenses (immune system) to attack the cancer.
BCG is an example of this type of treatment that is useful for treating low-stage bladder cancer. BCG is a type of bacteria that is sometimes used to vaccinate people against TB (tuberculosis). When used to treat bladder cancer, BCG is given directly into the bladder through a catheter. The body�s immune system responds to BCG. Immune system cells are drawn to the bladder and attack the cancer. It is usually given once a week for 6 weeks.
BCG treatment may cause flu-like symptoms (mild fever, chills, and tiredness) as well as a burning sensation in the bladder. A high fever (over 101.5 degrees) that does not respond to aspirin or Tylenol® could mean a life-threatening spread of BCG throughout the body. If that happens, you should call your doctor right away. Usually these infections can be treated with a drug used to treat tuberculosis.
Another form of intravesical treatment uses interferon (in-ter-fear-on), a substance normally made by the body. Other drugs are often given with the interferon to relieve common side effects such as muscle aches, bone pain, headaches, tiredness, nausea, and vomiting.
Chemotherapy
Chemotherapy (chemo) refers to the use of drugs to kill cancer cells. Usually the drugs are given into a vein or by mouth. Once the drugs enter the bloodstream, they spread throughout the body. Chemo is useful in treating cancer that has spread beyond the bladder to lymph nodes and other organs.
Chemo might be used to shrink a large tumor so it can be more easily removed during surgery. When used this way it is called neoadjuvant chemotherapy (giving the drugs before the local treatment). It can also be given after surgery to prevent the growth of stray cancer cells still in the body. This is called adjuvant chemotherapy (giving the drugs after local treatment such as surgery or along with radiation). Many studies have found that using chemo either of these ways lowers the chance that the bladder cancer will come back.
While chemo drugs kill cancer cells, they also damage some normal cells and this can lead to side effects. These side effects will depend on the type of drugs used, the amount taken, and the length of treatment. Temporary side effects might include:
- nausea and vomiting
- not feeling hungry
- hair loss
- mouth sores
- greater chance of infection (from a shortage of white blood cells)
- bleeding or bruising after minor cuts or injuries (from a shortage of blood platelets)
- tiredness (from low red blood cell counts, called anemia)
Most of these side effects go away when treatment is over. If you have any problems with side effects, be sure to tell your doctor or nurse, as there are often ways to help.
Chemo can cause long-lasting side effects such as early menopause and infertility. Older women treated with chemo have a higher chance of these side effects.
Sometimes chemo is placed directly into the bladder (intravesical) rather than being given by mouth or injection. Because drugs given this way only reach cancer cells near the bladder lining rather than those in other organs or deep in the bladder wall, this treatment is used only for early stage bladder cancer.
One of the main advantages of giving drugs directly into the bladder is that they don�t usually spread throughout the body. This means that there is less chance of side effects throughout the body. The main side effect of intravesical chemo is irritation and a burning feeling in the bladder.
Radiation Therapy
Radiation therapy is treatment with high-energy rays (such as x-rays) to kill or shrink cancer cells. The radiation may come from outside the body or from radioactive materials placed directly in the tumor. After surgery, radiation can kill small deposits of cancer cells that may be too small to see.
After transurethral surgery, giving radiation therapy and chemotherapy together can sometimes destroy cancers that would otherwise require cystectomy. If the tumor is in a position that makes surgery difficult, radiation may be used to shrink the tumor, making it easier to remove. Radiation might also be used to ease the symptoms of advanced cancer.
Mild skin irritation, nausea, bladder irritation, diarrhea, or fatigue may occur after radiation therapy. These problems usually go away after treatment ends. If you have these or other side effects, you should talk to your doctor. Often there are ways to help.
The outlook for recovery and the type of treatment for bladder cancer that comes back (recurrent bladder cancer) depends on the place and size of the cancer and what kind of treatment was used the first time.
Bladder Cancer Survival by Stage
The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is found. Of course, many people live much longer than 5 years. Five-year relative survival rates don�t count patients who died from other diseases. This means that anyone who died of another cause, such as heart disease, is not counted. This makes this the relative survival rate more accurate.
| Stage | 5-year Relative Survival Rate |
| 0 | 95% |
| I | 85% |
| II | 55% |
| III | 38% |
| IV | 16% |
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