All you need to know about bladder cancer

When Frances Dobrowolski noticed blood in her urine in August 2019, she didn’t think much of it. But then it happened again, and since she was scheduled to see her general practitioner in two weeks, she mentioned that strange fact.

Her doctor immediately referred her to a urologist, and it proved life-saving for the 78-year-old retiree and grandma from New Hampshire in the United States. When her urologist threaded a tube with a tiny video camera into her urethra and bladder (a cystoscopy), she immediately saw the cancerous tumours. Dobrowolski, who was able to watch the procedure on a screen, also saw the tumours—they were growing from her bladder walls into the bladder. “It was a lot of cancer,” she says.

Frances also learned that smoking could have been the cause. “I quit 13 years ago, but I smoked for 40 years, two packs a day,” she says. “I thought if I got anything, it would be lung cancer, but I got bladder cancer instead.”

Frances had surgery to remove the tumours within days, but on the follow-up test a few weeks later, more cancer showed up on the screen, so she had a second surgery. She also started a regimen of having chemotherapy drug infusions, once a week for six weeks, into her bladder to kill the remaining tumour cells.

When her next checkup revealed another tumour, she needed more infusions. “But because I saw my doctor as soon as I spotted symptoms," she says, "and because the tumours aren’t growing into my muscles, my prognosis is good. I stay optimistic.”

About 550,000 people worldwide were diagnosed with bladder cancer in 2018. In the European Union about 120,000 people are diagnosed annually with bladder cancer, and about 40,000 people in the EU die from the disease every year. 

Many bladder cancers are highly treatable like Frances’. The key to beating it is early detection—and that’s where things get tricky. Unlike with prostate or breast cancers, there’s no test that can detect an elevated risk of bladder cancer, so patients have to spot the troubling signs themselves.

Symptoms

The most telling sign of bladder cancer is the sudden appearance of blood in urine, a symptom called haematuria, which Frances had. The moment you see it, you should call your doctor right away, rather than waiting for it to disappear. Haematuria may not be accompanied by any pain, so some patients wait for it go away, losing precious time.

In addition to blood in the urine, symptoms may include changes in urination, such as a burning sensation, pain, and increase in frequency and urgency. These symptoms can be deceptive because people may attribute them to age or an overactive bladder, and ignore them. And when they finally share their concerns with their general practitioners, the doctors sometimes mistake them as urinary tract infections (UTIs).

Risk Factors, Gender & Age

Smoking is the single most important risk factor in developing bladder cancers, according to research. When inhaled, the smoke toxins pass through the lungs and percolate through the bloodstream until they are filtered out of the body by the kidneys, mixing into the urine. That toxin-high urine can remain in the bladder for hours, essentially poisoning its walls.

“When patients quit smoking,” says Dr. Antoine G. van der Heijden, a urologist at the Radboud University Medical Centre in Nijmegen, Netherlands, “the chances of cancer coming back or evolving will decrease, and survival will increase.”

More men develop bladder cancer than women. According to 2015 statistics, the overall number of new cases in the European Union comprised about 103,000 men and 28,000 women—and doctors think that’s because there are more smokers among men.

However, even though bladder cancer affects fewer women, their survival chances are slightly lower than men’s—and there might be several reasons for that, experts say.  The disease may progress faster in women because their bladder walls are thinner, allowing certain tumours to spread more easily and invade other organs. Hormones such as estrogen might play a role, too. And because women are more susceptible to urinary tract infections, doctors often misinterpret their symptoms.

Most women with cancer whose first symptom is blood in their urine are initially misclassified as having a UTI, says Dr. Renate Pichler, a urologist at the Medical University of Innsbruck. So, she says, if you have been treated with several rounds of antibiotics and your infection isn’t subsiding, that’s not normal. It’s time to see the urologist and do a bladder cancer check.

Age doesn’t play a big role in bladder cancer, but the average age of diagnosis is 73. “The highest incidence is seen in the age group 70 to 75,” Dr. van der Heijden says.

Types of Bladder Cancer

There are important differences between types of bladder cancer. Most patients (including Frances Dobrowolski)—about 75 percent—develop less-aggressive urothelial carcinomas, which start in the urothelial cells that line the inside of the bladder. Most of these tumours are slender, finger-like protrusions, growing from the bladder’s inner surface and towards its hollow centre rather than into its walls and out of the bladder into the surrounding tissues. Dr. van der Heijden adds that some types of urothelial carcinomas can be more aggressive than others, so doctors differentiate them by grades that range from zero to four, with higher numbers being more invasive.

The remaining 25 percent of patients have more aggressive cancers. Carcinoma in situ, or CIS, begins as a non-invasive tumour but it tends to grow and spread more quickly and has a higher chance of recurrence. Nearly half of CIS patients will eventually develop a muscle-invasive tumour, says Dr. van der Heijden.

Certain rare types of bladder cancers can be muscle-invasive from the start. These are very aggressive, but each constitutes only about one percent of all bladder cancer cases. Patients’ prognosis and treatment depend on their tumours’ type and stage.

Diagnosis & Treatments

As Frances discovered, to diagnose the cancer urologists perform a cystoscopy. This allows the doctor to view the bladder’s inner lining on a computer screen and get a sample for a biopsy. Sometimes doctors also order a fluorescence cystoscopy, which uses a drug activated by blue light to find abnormal cells. Or, the doctor may order a CT scan or MRI with a contrast dye that highlights tumours, allowing the doctor to determine the exact type and stage of the cancer present.

Non-muscle-invasive cancers, as in Frances’ case, are removed by a procedure called a transurethral resection of the bladder tumour. A thin instrument is inserted through the urethra and into the bladder. It has a wire loop at the end that removes the tumour. An electrode or laser is then used to destroy remaining abnormal cells, which may not necessarily be part of the tumour.

After the surgery, doctors may also use a catheter to inject a liquid drug directly into the bladder to kill any remaining cancer cells. This type of treatment is called intravesical therapy. More aggressive cancers might require multiple applications administered over months and even years, with the exact regimen designed to address the patient’s specific case.

Patients must also have regular cystoscopy check-ups after surgery to make sure the cancer doesn’t return, because urothelial carcinomas tend to grow again. But with careful monitoring future cancers can be prevented from taking hold.

Piet van Klaveren* can attest to that. His bladder cancer fight began in 1996. It was detected because of blood in his urine—which he ignored at first. “Like most men, I postponed it, hoping it would go away,” recalls the 73-year-old pharmacist in Wageningen, Netherlands. When he finally mentioned it to his GP a few months later, he was immediately referred to a urologist who diagnosed him with a non-muscle-invasive urothelial carcinoma—so his prognosis was good.

Piet had surgery, but a year later the cancer came back. This time, after scooping it out, Piet’s doctor used intravesical therapy, injecting a chemotherapy drug into his bladder over the course of a year. Piet remained cancer-free for a decade until in 2011 he spotted blood in his urine once again. And once again he had surgery followed by intravesical therapy over four years.

“I’m currently free of cancer,” he says, noting that regular surveillance is key to staying that way. “It’s checked twice a year with a cystoscopy.”

Dr. Pichler says that patients with early-stage non-muscle-invasive cancers can also receive immunotherapy that is administered via intervesical therapy that stimulates the immune system to attack cancer. 

In the case of muscle-invasive cancers and tumours that can’t be stopped by these means, doctors may recommend radical cystectomy—removing the bladder entirely. Then they can either construct a conduit that diverts urine from the kidneys into a small pouch worn on the body that patients empty manually, or they can reconstruct the bladder entirely, from a piece of the patient’s small intestine.

“Clinicians need to choose the right option for the right patients,” Dr. Pichler says.

The key to staying healthy after treatment is regular check-ups and cystoscopy tests, experts say. Usually, urologists do them every three months for the first two years, every six months for the next three years, and once a year after that, says Dr. Pichler.

For those spotting blood in their urine for the first time or having sudden onset of recurring UTIs—especially after never having them before—these are a reason for a thorough urological exam, Dr. van der Heijden says. Even having an actual UTI doesn’t rule out a tumour entirely, because the two may co-occur.

Keep this advice from Dr. van der Heiden in mind: “In women who suddenly have recurrent UTIs, analysis by a urologist is mandatory. In men, a single UTI is already a reason to be referred to a urologist.” 

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