Striking Blows Against Bladder Cancer

Learning about this often-overlooked cancer may save your life.

By Kari Bohlke, ScD

Many of us can recite basic facts about cancer. We know that breast cancer is the most common cancer in women (after skin cancer) and that lung cancer results in the highest number of cancer deaths. We worry about the tendency of ovarian cancer to be diagnosed at an advanced stage. We know the importance of pap tests and mammograms and colonoscopies. We pay attention to suspicious skin changes.

But what if someone asked you about bladder cancer? If you know anything about it, you’ve probably heard that it’s most common in older men. And this is true. Nevertheless, more than 17,000 women in the United States are diagnosed with bladder cancer each year. Furthermore, women tend to be diagnosed at a later stage than men and have worse survival prognoses.

Learning the facts about bladder cancer may help you recognize its early signs. In addition, avoiding exposure to carcinogens that have been linked with bladder cancer—such as tobacco smoke—will help you reduce your risk of developing the disease.

Bladder Basics

The bladder is a hollow organ in the pelvis. Its primary function is to store urine (the waste produced when the kidneys filter the blood). Urine enters the bladder through two tubes called ureters and leaves the bladder through a single tube called the urethra. The bladder has a muscular wall that allows it to get larger and smaller as urine is stored and emptied.

The bladder is composed of several different layers of tissue. The inner lining of the bladder is composed of several layers of cells known as transitional cells. Underneath the transitional cells is a layer of connective tissue known as the lamina propria. The muscular wall of the bladder—known as the muscularis propria—forms the layer beyond the lamina propria. A layer of fatty tissue forms the final, outermost layer of the bladder.

Risk Factors for Bladder Cancer

Many bladder cancers are thought to be caused by exposure to cancer-causing agents that pass through the urine and come into contact with the bladder lining. The most significant risk factor for bladder cancer is smoking, which increases risk by at least fourfold.3 Occupational exposure to chemicals such as benzene also increases risk; and workers in the dye, rubber, and chemical industries may have an increased risk of bladder cancer, along with painters and leather workers.4 Other exposures that may increase your risk include certain chemotherapy drugs and radiation to the pelvis; arsenic in well water; and repeated urinary tract infections or other sources of chronic bladder irritation, such as prolonged use of a catheter.5

Although these characteristics and exposures can help identify individuals at increased risk of bladder cancer, and also suggest ways to reduce risk, they are not perfect predictors of who will develop the disease. Bladder cancer can develop in individuals with none of the known risk factors and may never develop in individuals with several of the risk factors.

Overview of Bladder Cancer

A large majority of bladder cancers (more than 90 percent) begin in the transitional cells that line the inside of the bladder.6 These cancers are called transitional cell cancers or urothelial cancers and are the focus of this article. Other, less common types of bladder cancer include squamous cell cancer and adenocarcinoma.

At the time of diagnosis, an estimated 70 to 80 percent of patients will have what is referred to as “superficial” bladder cancer.7 This refers to cancer that has not yet reached the bladder muscle. Superficial bladder cancer may involve only the transitional cells (Stage 0 bladder cancer) or may extend into the second layer of the bladder—the lamina propria (Stage I bladder cancer).

The remaining patients are diagnosed with bladder cancer that has spread to the bladder muscle or beyond. Stage II bladder cancer invades the bladder muscle; Stage III bladder cancer has spread to the fatty layer that surrounds the bladder and may also have spread to nearby reproductive organs; and Stage IV bladder cancer has spread to lymph nodes or other sites in the body.

Diagnosis of Bladder Cancer

The most common sign of bladder cancer is blood in the urine (hematuria).8 The hematuria caused by bladder cancer tends to be painless and is often intermittent (comes and goes). Other possible signs of bladder cancer include painful urination, increased frequency of urination or urge to urinate, or difficulty urinating.

When bladder cancer is suspected, patients often undergo a cystoscopy, which involves the insertion into the bladder (through the urethra) of a small tube with a lens and a light at the end that allows a physician to view the inside of the bladder. During a cystoscopy the physician may take samples of tissue from areas of the bladder that appear abnormal.

Another test that may be performed is urinary cytology. In this test a pathologist evaluates cells in the urine to detect cancer cells. Newer tests—such as UroVysion™ and NMP22® BladderChek®—may also play a role in the initial diagnosis of bladder cancer, although the optimal approach to using these tests is still being defined.9

Patients may also undergo imaging procedures such as intravenous pyelogram (IVP), computerized axial tomography (CT), magnetic resonance imaging (MRI), bone scan, or chest X-ray to identify cancer in other parts of the urinary tract or the body.10

Treatment of Bladder Cancer

Depending on your treatment plan, several different types of physicians may be involved in your care. These may include urologists, medical oncologists, and radiation oncologists. Urology is a medical specialty that focuses on care of the urinary tract in both men and women as well as male reproductive health.

Treatment of bladder cancer generally includes surgery. For patients with superficial bladder cancer, surgery often involves transurethral resection (TUR), the insertion of a surgical instrument through the urethra to remove the abnormal areas of the bladder lining. TUR may be accompanied by the delivery of immunotherapy or chemotherapy drugs directly to the bladder through a catheter in the urethra (intravesical therapy).11

Patients with deeper or more-extensive cancer may require a radical cystectomy and a urinary diversion.12 In women a radical cystectomy generally involves removal of the bladder and many adjacent organs, including the uterus, fallopian tubes, ovaries, and part of the wall of the vagina. Because more-extensive cancers may already have spread beyond the bladder, systemic (whole-body) chemotherapy may be administered before or after surgery.

A study published in the New England Journal of Medicine reported that patients with muscle-invasive bladder cancer who received chemotherapy prior to cystectomy had significantly better survival than patients treated with cystectomy alone.13 Some patients may be candidates for bladder-sparing treatment (also known as trimodality therapy), which involves TUR, systemic chemotherapy, and radiation therapy.14

Because the bladder is removed during a radical cystectomy, the surgeon must create an alternative way for urine to be stored and passed. There are different approaches to urinary diversion. Using one approach, the urine drains through a stoma (an opening in the skin) to a bag attached to the outside of the body. Using another approach, the urine collects in a pouch inside the body and is periodically emptied by passing a catheter through the stoma. It may also be possible to surgically re-create a bladder that connects to the urethra.

For patients with cancer that has spread from the bladder to distant sites in the body, chemotherapy is a common treatment.15 Because available treatments often have limited effectiveness in patients with metastatic bladder cancer, patients may wish to consider participating in a clinical trial of new therapeutic approaches.

Finally, it is important to note that bladder cancer has a high rate of recurrence. Patients who have been diagnosed with bladder cancer will need to be regularly monitored for recurrence after treatment is completed.

Bladder Cancer in Women

The good news for women is that bladder cancer is less common in women than men;

the bad news, however, is that women have a worse prognosis. Five-year survival among bladder cancer patients in the United States is 82 percent for men and 75 percent for women.16 This difference in prognosis is explained at least in part by the fact that women tend to be diagnosed at a later stage than men. A study of more than 30,000 bladder cancer patients in the United States reported that roughly 25 percent of women had cancer that had spread to the bladder muscle or beyond at the time of diagnosis compared with roughly 21 percent of men.17 African-American women were particularly likely to be diagnosed with a later stage of cancer—roughly 43 percent were diagnosed with cancer that had spread to the bladder muscle or beyond.

Why the delay in diagnosis? In women symptoms of bladder cancer may initially be attributed to other common conditions, such as a urinary tract infection or uterine bleeding. A study presented at the 2006 meeting of the American Urological Association reported that men with hematuria were 65 percent more likely to be referred to a urologist than women with hematuria.18 This unequal access to specialty care may contribute to delayed diagnosis in women.

Later stage at diagnosis may not explain all of the gender difference in bladder cancer prognosis, however. Even after accounting for stage at diagnosis, a large study found that women still had worse survival than men.19 Among patients with Stage IV bladder cancer, for example, five-year relative survival was 27 percent in men and 15 percent in women. A similar (though somewhat less dramatic) pattern was also observed among patients with earlier-stage disease. The reasons for this worse survival in women are uncertain.

When the Statistics Don’t Matter

It’s true that as a woman you’re less likely to develop bladder cancer than many other types of cancer. But the statistics don’t matter if you’re one of the several thousand women in the United States who will develop bladder cancer this year. Learning to recognize early signs of the disease may allow for earlier diagnosis and more-effective treatment, and being aware of risk factors may provide additional motivation to make healthy changes in your life.

A Survivor’s Story

Joan Fowler’s story is all too common. Diagnosed with Stage I bladder cancer at the age of 50, the New Hampshire resident acknowledges that she’d been experiencing symptoms for years before her diagnosis. “I was told I had chronic cystitis,” she explains. “They just kept giving me antibiotics. For a while I would feel better, but then the symptoms would come back. I was urinating very brightly colored blood, but no one seemed particularly concerned about it.” Nevertheless, Joan had a feeling that something was seriously wrong. Eventually, after urination became “almost impossible,” she went to see her doctor again. This time an intravenous pyelogram (IVP) showed evidence of cancer throughout roughly 80 percent of the lining of her bladder.

The next step was a visit to the local urologist. After hearing that the urologist thought her bladder would have to be removed, Joan and her husband just looked at each other. As the news sank in, the tears began. Fortunately, her husband insisted on a second opinion. Joan traveled to the Dartmouth-Hitchcock Medical Center, a two-and-a-half-hour drive from her home. There she saw a urologist whom she describes as “a saint.” A specialist in bladder cancer, the urologist decided that he could remove the cancer without removing Joan’s bladder.

After surgery, the urologist recommended that Joan receive intravesical (within the bladder) treatment with Bacillus Calmette-Guerin (BCG) immunotherapy. “In my stupidity,” Joan says, “I decided not to do it.” A year later Joan began having symptoms again, and a return visit to the urologist revealed several additional tumors in her bladder. Joan once again had surgery to remove the tumors, and this time she followed her urologist’s recommendations about BCG. Since that time she has had surgery to remove two additional tumors, coupled with intravesical mitomycin.

Joan’s husband has continued to play an important role throughout her treatment. “When I was first diagnosed,” she says, “I was very depressed. But my husband was there to say, ‘No, you are going to the doctor and we are taking care of this and you are going to be fine.’ I’ve been very lucky to have that kind of support.” Joan advises husbands of newly diagnosed women to listen, be patient, and learn as much about the cancer as they can.

Asked if she has recommendations for other women, Joan says, “Listen to your body. Trust your feelings. Do research. And if you’re having symptoms, get more than one opinion.” Joan also encourages women to seek prompt care regardless of their insurance or financial situation. She had no health insurance at the time of her diagnosis, and she and her husband—who is disabled—live on a Veterans Administration pension. “Obviously, I am proof that there are agencies that will help, so don’t put anything off; you could lose not just your bladder but also your life.” Joan recommends talking with the hospital’s financial aid department if you need assistance, as well as with your state’s social services department. (For other suggestions about what to do if you’re uninsured, see the sidebar.)

Finally, Joan notes that while no one should have to go through the experience of cancer, good things have come out of it. “I’ve become a lot more spiritual than I was before. And I don’t take things for granted anymore.”

Possible Signs of Bladder Cancer

  • Blood in the urine
  • Painful urination
  • Increased frequency of urination or urge to urinate
  • Difficulty urinating

These symptoms can also be caused by conditions other than bladder cancer and should be discussed with your physician.

Bladder Cancer Statistics

  • Each year in the United States, bladder cancer is diagnosed in roughly 50,000 men and 17,000 women.20
  • Bladder cancer is most common in older individuals, with more than 70 percent of cases diagnosed after the age of 65.21
  • Bladder cancer is diagnosed roughly twice as often in Whites as in African Americans, but Blacks have worse survival with bladder cancer.22
  • Five-year survival with bladder cancer ranges from approximately 95 percent for Stage 0 cancer to 16 percent for Stage IV cancer.23

Bladder Cancer Resources

  • Bladder Cancer Advocacy Network

www.bcan.org

  • Bladder Cancer WebCafé

http://blcwebcafe.org

  • Treatment information from the National Comprehensive Cancer Network

www.nccn.org/patients/patient_gls/_english/_bladder/contents.asp

  • Urostomy information from the American Cancer Society

www.cancer.org/docroot/cri/content/cri_2_6x_urostomy.asp

  • Cancer Consultants news and treatment information on bladder cancer

http://news.cancerconnect.com/types-of-cancer/bladder-cancer/

Uninsured and Facing Cancer? There Is Help Available!

Tips from the Patient Advocate Foundation

Group Health Benefits/COBRA. Determine if health coverage is available through your or your partner’s employment or through a COBRA plan if you or your partner has recently left employment. Visit www.dol.gov or call (866) 444-3272.

Medicaid. Apply for Medicaid through your county department of social services. Share-of-cost or spend-down programs may be available if you do not meet the income/asset guidelines. A denial from Medicaid is often a requirement for applying to other programs. Visit www.cms.hhs.gov.

County Medical Assistance. Apply for a county Medical Assistance Program when denied Medicaid—if it’s available in your county. The program is a coordinated system for the low-income uninsured of the county to access needed medical care on a sliding-scale or no-cost basis. Contact your local Medicaid office to learn more.

Risk Pool Coverage. Apply for risk pool coverage, which provides health insurance options for high-risk individuals. These are state programs that serve people who have preexisting health conditions who are often denied or find it difficult to obtain affordable healthcare coverage in the private market. Contact your state commissioner or visit www.naschip.org/states_pools.htm to determine if your state offers this coverage.

HillBurton Free Hospital Care. The Hill-Burton program was established in 1946 when Congress passed a law that gave many hospitals and other healthcare facilities federal funds to meet their construction and/or modernization needs. In return these facilities are required to provide a specific amount of free or reduced-cost healthcare. Visit www.hrsa.gov or call (800) 638-0742.

Charity Care/Discounts. Discuss charity care whether partial or full with all facilities, doctors, and hospitals involved. Self-pay discounts are generally available.

Medication Assistance. Apply for the indigent drug program offered to qualified individuals for free or low-cost medications, including chemotherapy. Visit www.needymed.com or www.helpingpatients.org to determine if this type of program covers your prescribed medication.

Clinical Trials. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. The development of more-effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Each clinical trial is designed to find new or better ways to treat cancer patients. Clinical trials also provide an avenue to care for the uninsured or underinsured. Some trials absorb most or all of the treatment expense and can be a cost-effective way to access care. The National Institutes of Health (NIH) offers a broad range of trials. The National Cancer Institute (NCI) offers only cancer-related trials. To be prescreened for these trials, call the NCI at (888) 624-1937 and the NIH at (800) 411-1222 to determine if you fit the criteria.

The Patient Advocate Foundation is dedicated to ensuring that all Americans have access to healthcare. Case managers are available to assist patients affected by debilitating or life-threatening illnesses by empowering them to make informed decisions regarding their healthcare options. For more information visit www.patientadvocate.org or call (800) 532-5274.

BIO

Kari Bohlke is a cancer epidemiologist who now works full-time as a medical writer. By writing about bladder cancer – a type of cancer that many women overlook – she hopes to improve the early recognition of this cancer in women. “Information plays such an important role in achieving the best possible cancer outcomes; I believe that we owe it to ourselves to learn as much as we can.” Kari would like to thank Joan Fowler for sharing her experience as a bladder cancer survivor. “Talking with Joan was a wonderful experience. She has a great outlook on life and is committed to helping other women recognize and survive this disease.”

References:

.   Cancer Facts & Figures 2007. American Cancer Society Web site. Available at: http://www.cancer.org/docroot/stt/stt_0.asp. Accessed April 9, 2007.

. Bladder Cancer Treatment Guidelines for Patients. Version II/June 2005. National Comprehensive Cancer Network Web site. Available at: http://www.nccn.org/patients/patient_gls/_english/_bladder/contents.asp. Accessed April 9, 2007.

3. Bladder and Other Urothelial Cancers (PDQ®): Screening. Health Professional Version. National Cancer Institute Web site. Available at: http://www.cancer.gov/cancertopics/pdq/screening/bladder/HealthProfessional. Accessed April 9, 2007.

4. Kirkali Z, Chan T, Manoharan M, et al. Bladder cancer: epidemiology, staging and grading, and diagnosis. Urology. 2005;66(6 Suppl 1):4-34.

5. Bladder and Other Urothelial Cancers (PDQ®): Screening. Health Professional Version. National Cancer Institute Web site. Available at: http://www.cancer.gov/cancertopics/pdq/screening/bladder/HealthProfessional. Accessed April 9, 2007.

6. Bladder and Other Urothelial Cancers (PDQ®): Screening. Health Professional Version. National Cancer Institute Web site. Available at: http://www.cancer.gov/cancertopics/pdq/screening/bladder/HealthProfessional. Accessed April 9, 2007.

7. Bladder Cancer (PDQ®): Treatment. Health Professional Version. National Cancer Institute Web site. Available at: http://www.cancer.gov/cancertopics/pdq/treatment/bladder/HealthProfessional. Accessed April 9, 2007.

8. Pashos CL, Botteman MF, Laskin BL, et al. Bladder cancer: epidemiology, diagnosis, and management. Cancer Practice. 2002;10(6):311-22.

9. Detailed Guide: Bladder Cancer. How Is Bladder Cancer Diagnosed? American Cancer Society Web site. Available at: http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_How_is_bladder_cancer_diagnosed_44.asp?sitearea=. Accessed April 9, 2007.

10. Bladder Cancer Treatment Guidelines for Patients. Version II/June 2005. National Comprehensive Cancer Network Web site. Available at: http://www.nccn.org/patients/patient_gls/_english/_bladder/contents.asp. Accessed April 9, 2007.

11. Bladder Cancer (PDQ®): Treatment. Health Professional Version. National Cancer Institute Web site. Available at: http://www.cancer.gov/cancertopics/pdq/treatment/bladder/HealthProfessional. Accessed April 9, 2007.

12. Bladder Cancer (PDQ®): Treatment. Health Professional Version. National Cancer Institute Web site. Available at: http://www.cancer.gov/cancertopics/pdq/treatment/bladder/HealthProfessional. Accessed April 9, 2007.

13. Grossman HB, Natale RB, Tangen CM, et al. Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer. New England Journal of Medicine. 2003;349(9):859-66.

14. Pashos CL, Botteman MF, Laskin BL, et al. Bladder cancer: epidemiology, diagnosis, and management. Cancer Practice. 2002;10(6):311-22.

15. Bladder Cancer (PDQ®): Treatment. Health Professional Version. National Cancer Institute Web site. Available at: http://www.cancer.gov/cancertopics/pdq/treatment/bladder/HealthProfessional. Accessed April 9, 2007.

16. Ries LAG, Harkins D, Krapcho M, et al. (eds). SEER Cancer Statistics Review, 1975-2003. National Cancer Institute Web site. Available at: http://seer.cancer.gov/csr/1975_2003/. Accessed April 9, 2007.

17. Cardenas-Turanzas M, Cooksley C, Pettaway CA, et al. Comparative outcomes of bladder cancer. Obstetrics and Gynecology. 2006;108(1):169-75.

18. Johnson E, Daignault S, Zhang Y, et al. Gender disparities in urologic referral of hematuria. Program and Abstracts of the American Urological Association 2006 Annual Meeting; May 20-25, 2006; Atlanta, Georgia. Abstract 887.

19. Mungan NA, Aben KK, Schoenberg MP, et al. Gender differences in stage-adjusted bladder cancer survival. Urology. 2000;55(6):876-80.

20. Cancer Facts & Figures 2007. American Cancer Society Web site. Available at: http://www.cancer.org/docroot/stt/stt_0.asp. Accessed April 9, 2007.

21. Ries LAG, Harkins D, Krapcho M, et al. (eds). SEER Cancer Statistics Review, 1975-2003. National Cancer Institute Web site. Available at: http://seer.cancer.gov/csr/1975_2003/. Accessed April 9, 2007.

22. Cancer Facts & Figures 2007. American Cancer Society Web site. Available at: http://www.cancer.org/docroot/stt/stt_0.asp. Accessed April 9, 2007.

23. Detailed Guide: Bladder Cancer. How Is Bladder Cancer Staged? American Cancer Society Web site. Available at: http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_How_is_bladder_cancer_staged_44.asp?sitearea=. Accessed April 9, 2007.