Bladder Cancer

Definition
A malignant tumour arising from the bladder wall. The commonest tumour in the UK is a transitional cell carcinoma (TCC). Other much less common tumours include squamous cell carcinoma, adenocarcinoma and lymphoma.

Incidence
Bladder cancer is the fourth commonest cancer in men and the eighth commonest in women. Men are affected 3 times more commonly than women. The peak incidence is in the seventh decade.

Causes 
The incidence of TCC is increased in smokers. There is also an increased incidence associated with some industries especially those involved with rubber and dyes. Squamous cell carcinoma is strongly associated with the tropical disease bilharzia (schistosomiasis).

Signs & Symptoms
The commonest symptom is blood in the urine (haematuria). This may be visible to the naked eye or only found on testing the urine. The presence of pain or the findings of a lump are much less common.

Complications
The tumour itself or blood clots from the tumour can obstruct the flow of urine and cause urinary retention. The tumour can obstruct the flow of urine from the kidneys to the bladder and cause renal impairment. The tumour can invade other organs such as the bowel, the prostate in men and the vagina, uterus and ovaries in women. Like most malignant tumours, spread to other more distant organs can also occur (metastases).

Investigations
The urine is examined for blood and may also be examined for malignant cells. The urinary tract will be imaged either by ultrasound, X ray or in some cases both. The bladder is examined by cystoscopy and biopsy to confirm the diagnosis.

Treatment

Early Disease
The initial treatment is a resection of the tumour carried out endoscopically (see transurethral resection of bladder tumour). If the disease appears to be confined to the lining of the bladder a single dose of chemotherapy instilled into the bladder via a catheter post-operatively may be given. This can cause stinging in the bladder and does not usually cause other symptoms. If the disease is confined to the lining of the bladder and does not appear particularly aggressive on pathological examination, it is likely that only regular cystoscopies possibly with further bladder instillations if you have frequent recurrences.

Muscle Invasive Disease
If the disease has extended into the muscular wall of the bladder, additional treatment either in the form of surgery (cystectomy) or radiotherapy will usually be recommended. Although surgery is the main treatment for bladder cancer, radiotherapy has an important role in cases where the cancer is not resectable or the patient is not fit for a major operation (see radiotherapy). Radiotherapy for bladder cancer can take between 4 weeks or over 6 weeks depending on the policy of the hospital. Side-effects during treatment include diarrhoea, inflammation of the bladder (cystitis), tiredness. Possible late side-effects include scarring of the bladder (fibrosis), inflammation of the rectum (proctitis), impotence and damage to small bowel (enteritis).

Incurable Disease
In cases where the cancer is too advanced or the patient is too ill to treat with a curative intention, treatment can be given to control the cancer and to relieve symptoms. The aim would be to improve and maintain quality of life rather than to cure (palliation). A short but sharp course of radiotherapy given over 1 and 2 weeks may achieve this if the symptoms are confined to the pelvis. Alternatively, chemotherapy can be given if the cancer has spread to other organs in the body (see chemotherapy). Th