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The bladder is a hollow muscular sac that stores urine. It is located in the pelvis and is part of the urinary system.

As well as the bladder, the urinary system includes two kidneys, two tubes called ureters leading from the kidneys into the bladder, and another tube called the urethra leading out of the bladder. In women, the urethra is a short tube that opens in front of the birth canal (vagina). In men, the urethra is longer and passes through the prostate and down the penis.

The kidneys produce urine, which travels to the bladder through the ureters. The bladder is like a balloon and inflates as it fills. The bladder muscle contracts, and urine is passed through the urethra and out of the body.

Bladder cancer begins when cells in the bladder's inner lining become abnormal, which causes them to grow and divide out of control. The treatment for bladder cancer depends on how quickly the tumour cells are growing and how far the cancer has spread into the layers of the bladder.

Each year, more than 2500 Australians are diagnosed with bladder cancer. Most people diagnosed with bladder cancer are 60 or older. Men are three to four times more likely than women to be diagnosed with bladder cancer. 

Treatment

Treatment for non-muscle-invasive bladder cancer

The main treatments for cancer cells in the bladder's inner lining (non-muscle-invasive bladder cancer) are surgery, immunotherapy and intravesical chemotherapy. Surgery, on its own or combined with other treatments, is used in most cases.

Surgery

Most people with non-muscle-invasive bladder cancer have an operation called transurethral resection of bladder tumour (TURBT). This is done during a cystoscopy under a general anaesthetic. 

Intravesical chemotherapy

Chemotherapy is the treatment of cancer with anticancer (cytotoxic) drugs. It aims to kill cancer cells while doing the least possible damage to healthy cells. Although the drugs are usually given as tablets or injected into a vein (systemic chemotherapy), in intravesical chemotherapy, the drugs are put directly into the bladder using a flexible tube called a catheter, which has been inserted through the urethra.

Intravesical chemotherapy is used only for non-muscle-invasive bladder cancer. It helps keep the cancer from coming back (recurrence). This form of chemotherapy can't reach cancer cells outside of the bladder lining or other parts of the body, so it's not suitable for muscle-invasive bladder cancer. Each treatment is called an instillation.

Treatment for muscle invasive bladder cancer

When bladder cancer has invaded the muscle, the most common treatment is surgery to remove the entire bladder. Other treatments, such as chemotherapy, may be given before or after surgery. Some bladder cancers may be treated with a combination of chemotherapy and radiation therapy only.

Surgery

Most people with muscle-invasive disease or cancer that has invaded the lamina propria and has not responded to BCG (a type of immunotherapy treatment), have surgery to remove the bladder (cystectomy).

Removing the whole bladder (radical cystectomy)

Radical cystectomy is the most common operation for muscle-invasive bladder cancer. The whole bladder and nearby lymph nodes are removed. In men, the prostate, urethra and seminal vesicles may also be removed. In women, the urethra, uterus, ovaries, fallopian tubes and a part of the vagina are often removed.

Removing part of the bladder (partial cystectomy)

This type of operation is not suitable for most types of bladder cancer, so it is less common. A partial cystectomy removes only the bladder tumour and a border of healthy tissue around it.

The most common treatment is surgery to remove the kidney, ureter and part of the bladder (nephroureterectomy). Sometimes, only part of the kidney or ureter needs to be removed, and in some cases, a laser can be used to remove the tumour endoscopically. You may have chemotherapy or immunotherapy after surgery.

Systemic chemotherapy

Chemotherapy is the treatment of cancer with anti-cancer (cytotoxic) drugs. It aims to kill cancer cells while doing the least possible damage to healthy cells.

For muscle-invasive bladder cancer, drugs are given by injection into a vein (intravenously). As the drugs circulate in the blood, they travel throughout the body. This type of chemotherapy is called systemic chemotherapy. It is different to the intravesical chemotherapy used for non-muscle-invasive bladder cancer, which is delivered directly into the bladder.

Radiation therapy

Radiation therapy, also known as radiotherapy, uses x-rays or electron beams to damage or kill cancer cells. It may be used instead of surgery to treat muscle-invasive bladder cancer. On its own, radiation therapy may not cure the cancer. Sometimes, chemotherapy is given with radiation therapy to make the radiation work better. This is called chemoradiation, and has been shown to work as well as surgery.

People who have chemoradiation will need to have regular cystoscopies after treatment.

Immunotherapy

Immunotherapy uses the body's own immune system to fight cancer. BCG is a type of immunotherapy treatment used to treat non-muscle-invasive bladder cancer.

A new group of immunotherapy drugs work by blocking barriers called checkpoints. These barriers are created by cancer cells to protect against attacks from the immune system. The checkpoint inhibitors help make the cancer cells visible to the body's immune system. Once the barrier is removed, the immune system can recognise and destroy the cancer.

Palliative treatment

Palliative treatment helps to improve people's quality of life by managing symptoms of cancer without trying to cure the disease and is best thought of as supportive care.

Many people think that palliative treatment is only for people at the end of their life; however, it can help people at any stage of advanced bladder cancer. It is about living for as long as possible in the most satisfying way you can.

As well as slowing the spread of cancer, palliative treatment can relieve pain and help manage other symptoms. Treatment may include radiation therapy, chemotherapy or targeted therapy.

Risk factors

Research shows that people with certain risk factors are more likely to develop bladder cancer. These include:

  • Smoking – cigarette smokers are up to three times more likely than nonsmokers to develop bladder cancer.
  • Older age – most people with bladder cancer are over 60, and the risk increases with age.
  • Being male – men are three to four times more likely than women to develop bladder cancer.
  • Chemical exposure at work – chemicals called aromatic amines, benzene products and aniline dyes have been linked to bladder cancer; these chemicals are used in rubber and plastics manufacturing in the dye industry, and sometimes in the work of painters, machinists, printers, hairdressers and truck drivers.
  • Chronic infections – squamous cell carcinoma has been associated with urinary tract infections (including parasite infections, although these are very rare in Australia) and untreated bladder stones.
  • Long-term catheter use – long-term urinary catheter use may be linked with squamous cell carcinoma.
  • Previous cancer treatments – treatments that have been linked to bladder cancer include the chemotherapy drug cyclophosphamide (used for various cancers) and radiation therapy to the pelvic area (sometimes given for prostate cancer and gynaecological cancers).
  • Diabetes treatment – the diabetes drug pioglitazone can increase the risk of bladder cancer.
  • Personal or family history – a small number of bladder cancers are associated with an inherited gene.

Early symptoms

Sometimes bladder cancer doesn't have many symptoms and is found when a urine test is done for another reason. However, often people with bladder cancer do experience symptoms. These can include:

  • Blood in the urine (haematuria)
  • Changes in bladder habits

Less commonly, people have pain in one side of their lower abdomen or back. Not everyone with the symptoms above will have cancer but see your general practitioner (GP) if you are concerned.

Never ignore blood in your urine. Even if you've noticed blood in your urine only once and it is painless, see your GP.

Diagnosis/diagnosing

To diagnose bladder cancer, your general practitioner (GP) may examine you and then refer you to a specialist. The tests you have will depend on your specific situation and may include:

Internal examination

As the bladder is close to the rectum and vagina, your doctor may do an internal examination by inserting a gloved finger into the rectum or vagina to feel for anything unusual. 

Blood and urine tests

Blood samples may be taken to check your general health.

You will also be asked to give a urine sample, which will be checked for blood and bacteria – this test is called a urinalysis. If you have blood in your urine, you may be asked to give three separate urine samples over three days, which will be sent to a laboratory to look for cancer cells – this test is called a urine cytology.

Ultrasound

An ultrasound scan uses sound waves to create a picture of your organs. It is used to show if cancer is present and how large it is. An ultrasound can't always find small tumours, so your doctor may do additional tests.

Cystoscopy

A cystoscopy is a common procedure for diagnosing bladder cancer. A thin tube with a light and a camera on the end (cystoscope) is used to examine the bladder's inner lining. The cystoscope may be flexible or rigid.

CT scan

A CT (computerised tomography) scan uses x-ray beams to take many pictures of the inside of your body and then compiles them into one detailed, cross-sectional image. If the scan is checking for urothelial carcinoma, it may be called a CT-IVP (intravenous pyelogram) or a triple-phase abdominal-pelvic CT.

MRI scan

Less commonly, an MRI (magnetic resonance imaging) scan may be used to check for bladder cancer. This scan uses a powerful magnet to build up cross-sectional pictures of organs in your abdomen. 

Radioisotope bone scan

A radioisotope scan may be done to see whether the cancer has spread to the bones. It may also be called a whole body bone scan (WBBS) or simply a bone scan.

A tiny amount of radioactive dye is injected into a vein, usually in your arm. The dye collects in areas of abnormal bone growth. You will need to wait several hours before having the scan. This gives the bones time to absorb the dye. The scanner will measure the radioactivity levels and record them on x-ray film.

X-rays

You may need x-rays if a particular area looks abnormal in other tests or is causing symptoms. A chest x-ray may be taken to check the health of your lungs and for any signs the cancer has spread. This is sometimes done with the CT scanner.

FDG-PET scan

This scan can be used to find cancer that has spread to lymph nodes or other sites that may not be picked up on a CT scan. Medicare does not currently cover the cost of an FDG-PET (fluorodeoxyglucose-positron emission tomography) scan for bladder cancer. If this test is recommended, check with your doctor what you will have to pay. PET scans are usually found only in major hospitals, so you may need to travel to have one.

Prognosis (Certain factors affect the prognosis and treatment options)

Bladder cancer can usually be effectively treated, especially if it is found before it spreads outside the bladder.

To work out your prognosis, your doctor will consider test results, the type of bladder cancer you have, the rate and depth of tumour growth, how well you respond to treatment, and other factors such as your age, fitness and medical history.

References

Some references are to overseas websites. There may be references to drugs and clinical trials that are not available here in Australia.