Bladder cancer

What is bladder cancer?
Bladder cancer is the result of cell changes in the mucous (inside) wall of the bladder. It is caused by changes in the cells' chromosomes or DNA (deoxyribonucleic acid). This form of cancer develops most often in people between the ages of 60 and 79, with the average age being 67. The disease is three times more common in men than in women. It is one of the most common forms of cancer to strike men.

How does bladder cancer develop?
In most cases, bladder cancer is caused by external factors. Cigarette smoking (because of harmful chemicals within the cigarette) and exposure to some carcinogenic (cancer causing) agents such as aromatic compounds and chemicals used in industry and elsewhere can lead to bladder cancer. Approximately 50 per cent of all cases are caused by tobacco smoking and 10 per cent by job-related factors. Stopping smoking, even after many years, can be beneficial, as ex-smokers have a lower rate of bladder cancer than those who continue to smoke. In the tropics, bladder cancer is often brought about by the widespread disease bilharziasis (river blindness), which is caused by a tiny micro-organism that invades the bladder.

What are the symptoms of bladder cancer?
Generally the first sign is blood in the urine. It may be visible or the amount may be so small that it can only be discovered by chemical testing ('stix' test). There does not need to be blood in the urine constantly. In fact, there are often periods in which there is no evidence of blood at all. So one should not be fooled by a symptom that seems to have gone away. There may be frequent urination, stinging and pain across the pubic bone or exactly the same symptoms as in an ordinary bladder infection.

How is bladder cancer diagnosed?
If blood is discovered in the urine or there are constant symptoms of bladder irritation of unknown cause, the patient should be examined by a doctor. In order to reach a diagnosis the GP will refer the patient urgently to the local hospital urology department for a series of special examinations. If a tumour is suspected, a procedure called a cystoscopy, is necessary, in which a doctor looks up into the bladder via the urethra using an instrument called a cystoscope. In addition, ultrasound scans or X-rays of the whole urinary tract are taken - an intravenous urogram. The urine may also be examined under a microscope for malignant cells. When the diagnosis has been made and the extent of the cancer is known, the type of treatment will be considered.

How is bladder cancer treated?
Treatment will differ according to the spread of the cancer. There are two main groups.

• Superficial cancer (non-invasive).

This means there is no evidence that the tumour has spread into the muscle coat of the bladder. The majority fall into this category and can usually be cured. Treatment is usually by cautery (burning of abnormal tissue) through a cytoscope or scraping the tissue away with a specially adapted telescopic instrument. There may be only one, or possibly several, tumours on the bladder. It is known that they can recur and the doctor will advise the patient to have regular checkup examinations by cytoscopy. Anti-cancer drugs such mitomycin C, or BCG (Bacillus Calmette-Guerin) are often used by installation into the bladder if it is confirmed that there is an increased risk of new cancers. If neglected, superficial cancer can progress to deep or invasive cancer.

• Deep cancer (muscle invasive)

The cancer has grown deeper to involve the muscle lining of the bladder. This is more serious as there is a greater risk that the cancer may spread to the lymph nodes or other organs such as the liver or bone. Further tests like a CT scan or MRI scans will help to confirm that the cancer is confined to the bladder. Treatment is usually a choice between radiation treatment or the total surgical removal of the bladder. If the bladder has to be surgically removed, urine from the kidneys is diverted to the skin surface just below the waist line using a small portion of the small bowel (known an ileal loop iversion). In this procedure, the tubes from the kidneys are joined to one end of a 12cm length of small bowel and the other end is brought out through the abdominal wall and onto the skin to form a stoma. A special adhesive bag is placed over the stoma to collect the urine. There is a tap on the bag to drain off the urine when necessary. In certain circumstances, a more sophisticated form of diversion can be constructed. Bowel can be made into a pouch with a tunnel to the skin surface through which the patient passes a small tube to drain the urine. Occasionally, a functioning bladder can be constructed from segments of bowel to form a continent bladder substitute, known as an orthotopic bladder substitute. If the cancer has spread to the lymph nodes or other organs, treatment with medicines (chemotherapy) may be offered.

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