Bladder cancer 101

Dr Thobile Goba-Mjwara educates us on bladder cancer and when catheters and adult diapers would be needed.

You can listen to this article below, or by using your favourite podcast player at pod.link/oncologybuddies

Bladder cancer, also known as urothelial carcinoma, occurs when a growth of abnormal tissue develops in the bladder lining. It’s common in people older than the age of 55.

There are two main categories of risk factors:

Patient factors: Male sex, white race, smoking, personal or family history of bladder cancer, previous pelvic irradiation, certain medical conditions including diabetes mellitus and obesity. While diabetes is associated with increased risk of developing bladder cancer, treatment with metformin is associated with improved prognosis.

Disease factors: Chronic infection like recurrent urinary tract infections (UTI), or urinary tract irritation like Schistosoma haematobium (Bilharzia). Genetic syndromes: Lynch syndrome, predispose to urothelial carcinoma. Genetic abnormalities in p53, RB and PTEN have been reported. Multifocal tumours are also common where cancer cells travel throughout the bladder, following exposure to carcinogens (field cancerization), increase risk of bladder cancer.

Screening and diagnosis

Screening isn’t advocated as cytology of haematuria (blood in urine) has low sensitivity. The gold standard for diagnosis is cystoscopy, an examination of the lining of the bladder via urethra (tube that carries urine from bladder to outside of the body) and biopsy.

Ninety to 95% of bladder cancers are transitional cell carcinoma type (TCC) and 10% make up adenocarcinoma, squamous cell, and clear cell type. Symptoms include urinary frequency; irritative voiding; haematuria; pain in the suprapubic region and or flanks.

Once a biopsy confirms bladder cancer, imaging of the urinary system is mandatory. Intravenous pyelogram (IVP), a special X-ray test of the kidneys, bladder, and ureters (tubes that carry urine from kidneys to the bladder) or kidney, ureter, bladder (KUB) X-ray is used.

A CT scan of the chest, abdomen and pelvis assesses distant metastatic spread. Bone scan is considered if there is bone pain.

Treatment

The clinical spectrum of bladder cancer is divided into three categories differing in prognosis, management, and therapeutic aims. Treatment depends on tumour grade, stage of disease, patient age, and physical status.

Non-muscle invasive bladder cancer

Treatment is directed at reducing recurrences and preventing disease progression. Transurethral resection of bladder tumour is treatment of choice. Low-grade tumours may require more resections to remove all visible disease followed by a single-dose intravesical chemotherapy (given directly into bladder).

Patients with high-grade disease require re-resection prior to initiation of intravesical Bacillus Calmette-Guerin (BCG) therapy. Re-resection is important, to eliminate any visible residual disease and eliminate the risk of under-staging. Intravesical immunotherapy with BCG is mandatory for patients with high-risk disease. During periods of BCG shortage, intravesical chemotherapy agents may be used (mitomycin, epirubicin and gemcitabine).

Muscle invasive bladder cancer

Goal of therapy is to determine if the primary lesion can be managed independently or if patients are at high risk for distant spread requiring systemic approaches to improve likelihood of cure.

Radical cystectomy, with urinary diversion is standard. This entails removal of the bladder, adjacent organs, and regional lymph nodes. In males, prostate, seminal vesicles, and urinary bladder are removed. In females, preservation of the uterus, cervix, and ovaries is possible due to infrequent tumour involvement of these organs.

Removal of the bladder requires redirection of urinary flow (urinary diversion) which may take one of several forms: Ileal conduits; cutaneous continent reservoir; or orthotopic neobladder. In addition to patient preference, choice of diversion is individualised based upon the patient’s medical condition, disease extent and prior treatment.

Metastatic bladder cancer

Critical goal is to prolong quantity and maintain quality of life. Numerous systemic agents have anti-tumour effects. The aim is to use these agents to achieve the best outcome. Palliative radiotherapy (high energy X-rays that kill cancer cells) is used to control bleeding and pain.

Use of urinary catheters and adult diapers

Urinary catheters may be indicated in these scenarios:

• Urinary retention with/without bladder outlet obstruction.
• During and following surgery to assess fluid status.
• Intravesical pharmacologic therapy.
• Patient comfort for end-of-life care.

Adult diapers are important short-term interventions to absorb heavy leaks and incontinence. Patients who have had an orthotopic neobladder may experience incontinence. This may happen until the neobladder stretches to a typical size and the muscles that support it get stronger. Daytime bladder control usually improves over the first six to 12 months after surgery. Night-time continence may continue to improve through the second year. Persistent problems with incontinence are more common during the night.

Header image by Freepik