Everything You Need To Know About Bladder Cancer

This blog was originally published on U.S. News and World Report.

Bladder cancer is the fourth most common cancer in men and the sixth most common type of the disease overall. But it’s a relatively under-recognized cancer, says Dr. Arjun Balar, director of the genitourinary medical oncology program at Perlmutter Cancer Center at NYU Langone Health. There are roughly 77,000 cases in the U.S. each year and about 16,000 disease-related deaths, he says.

What Causes Bladder Cancer

The bladder, which is located in the lower abdomen, is an organ that basically works like a balloon, says Dr. Ganesh Raj, a professor of urology at UT Southwestern Medical Center. “It stores urine, which the kidneys make and filter, until you’re ready to pee it out.” Raj says the inside of the bladder is lined with a specific type of mucosa cell that isn’t found anywhere else in the body. These cells allow the bladder to change shape and to stretch when the bladder is full.

Because the bladder primarily functions as a storage unit to hold waste products, Raj says it’s repeatedly exposed to substances that can be toxic, including ammonia, urea and environmental metabolites, like aromatic amines (organic compounds found in manufacturing and tobacco smoke). “Of all the cancers, bladder cancers have the greatest environmental component,” he says. In fact, like lung cancer, the No. 1 risk factor for bladder cancer is smoking. Raj says bladder cancer patients are often multi-pack year smokers. The other primary risk factors are chronic bladder infections, exposure to other environmental mutagens and prior radiation or chemotherapy.

Most patients with bladder cancer present with blood in the urine or symptoms of a UTIthat don’t get better, such as frequent urination, pain during urination or lower back pain. This prompts the patient to see a urologist, who examines the inside of the bladder with a lighted tube, or a cystoscope. If he or she sees cancer, the patient will undergo a transurethral resection, in which the doctor scrapes the inside of the bladder to remove the cancer.

The Type and Stage of Cancer Matters – a Lot

If you’re diagnosed with bladder cancer, the two things that matter most are the grade and stage of the tumor, Raj says. Tumor grade can be high or low. Raj says people with low-grade tumors have a high chance their tumor will recur within five years. Nevertheless, their prognosis is still good. Patients with high-grade tumors have a high chance their tumors will recur and progress to invasive cancer that can spread outside the bladder. Patients with high-grade cancers must be monitored closely for both recurrence and progression.

“Stage refers to the depth of the invasion into the bladder wall,” Raj says. If the tumor is completely confined to the mucosa, it’s a low-stage cancer, and that’s good. Low-stage cancers rarely progress to more invasive forms and are associated with a good prognosis. If the cancer starts going through the wall and into muscle (invasive), that’s a higher stage cancer and is associated with worse outcomes. It can potentially metastasize, and you have to be more aggressive treating it, he says.

Treatment for Bladder Cancer

“About 70 percent of people diagnosed in the U.S. will have what is called non-muscle-invasive bladder cancer,” Balar says. It grows primarily in the epithelium (the thin inner layer) and sub-epithelium, but not into the muscle, and less often develops into disease that is more aggressive. These patients will undergo transurethral resection and, depending on the stage and grade, may also receive Bacillus Calmette-Guérin, or BCG, a type of immunotherapy for bladder cancer that is placed directly into the bladder, Balar says.

“These patients should be monitored every three to six months,” Raj says, “and if there’s something there, we remove it with transurethral resection and make sure it hasn’t progressed into invasive cancer.” Fortunately, he says, about 85 percent of low-grade bladder cancers will stay low-grade, even when they recur. Individuals with non-invasive, superficial bladder cancers have a 95 percent or greater five-year survival rate, Raj says.

The other 30 percent of patients have cancer that has invaded the muscle wall of the bladder. The biology of these tumors is much more aggressive, Balar says. About 50 percent of patients are at risk for metastatic spread (stage 4), which develops most commonly in the first few years following surgical removal of the bladder (radical cystectomy), which is the standard of care. Thus, they are monitored aggressively with CT scans and MRIs after surgery.

“In addition, about 20 to 30 percent of patients with high-grade, non-muscle invasive disease will progress to the point where they ultimately need radical cystectomy,” Balar says. “Following a cystectomy, patients will need a urinary diversion to collect urine, either via a conduit that drains externally into a bag or via a new bladder, called a neobladder. Both are constructed from a portion of the small intestine.”

Raj says it used to be that standard chemotherapy was the only choice available to treat patients with metastatic bladder cancer. However, the U.S. Food and Drug Administration has now approved five immunotherapy drugs for bladder cancer in patients for whom chemotherapy no longer controls the cancer.

“Bladder cancer is a nuanced cancer,” Raj says. “One of the most important things we tell everyone is to have someone who is an expert treat your cancer, someone who knows the literature and the clinical trials. This is critical in outcomes, especially with all these new therapies. There’s a lot of potential hope for patients with advanced bladder cancer.”