Bladder cancer is a disease of the cells in the inner lining of the bladder. It develops from a normal cell that transforms itself, then multiplies in an anarchic fashion, until it forms a tumor.

The bladder is a stretchy hollow organ that functions like a reservoir. Its wall is structured in three layers: in the outer layer lie nerves as well as blood and lymph vessels, the middle layer consists of muscle tissue and the inside the bladder is lined by a mucosal layer.

The bladder belongs to the system of urinary tract. The latter is responsible for collecting and transporting the urine and consist of two sections: the kidneys and the ureters belong to the upper section, the bladder and the urethra form the lower part. The urinary excretion regulates the water and salt balance of the body.

The urine enters the bladder from the two kidneys through the ureters. There it is collected and emptied at the appropriate amount. In adults, the bladder can absorb up to one liter of liquid. The way out of the bladder leads through a funnel-shaped outlet into the urethra. From there, the urine is released outwards. In women, the urethra is only 3-5 centimeters long and flows into the vaginal atrium; in men, on the other hand, the urethra is about 24 centimeters long. It runs through the prostate and penis to the glans.

The bladder neck and urethra are surrounded by a sphincter that controls bladder function and urine excretion through fine coordination of muscles and nerves.

In the United States, bladder cancer represents about 4.5% of all diagnosed cancers. According to the American Cancer Society, 81,400 cases of bladder cancer are predicted for the year 2020. 17,980 are expected to die from the disease.

Symptoms of bladder cancer

Bladder cancer may not cause any signs or symptoms in the very early stages of the disease. Signs and symptoms often appear as the tumor grows or grows deeper into the wall of the bladder. Furthermore, other medical conditions can cause the same symptoms as bladder cancer.

The most common sign of bladder cancer is blood in the urine (hematuria). This may change the color of the urine, which may turn orange, pink or red. Sometimes the amount of blood in the urine is so small that it cannot be seen with the naked eye and can only be seen under a microscope during a urinalysis.

The following are other signs and symptoms of bladder cancer:

• need to urinate more often than usual
• urgent need to urinate
• burning or pain when urinating
• difficulty urinating or weak urine stream
• pain in the lower back or pelvis

People at risk

• People who have had other cancer of the urinary tract
• Men are more at risk than women
• People who have a permanent infection of the bladder with a parasite called bilharzia.

Diagnosis

First, your doctor will have a detailed conversation with the patient about the exact complaints and personal medical history. Various tests will then be initiated.

As a first step, a urine test is usually carried out to check, for example, whether blood can be detected in the urine. In addition, a uriny cytology is initiated. This is an examination of urine for malignantly altered cells.

If blood is detected in the urine, the next step is to perform an X-ray examination of the urinary tract, a so-called urography. Before undergoing the X-ray, a iodine-containing contrast agent is injected into the vein. This thus spreads over the bloodstream and kidneys and fills the urinary tract. Subsequently, several X-rays are taken every few minutes, which gives an overview of the entire urinary tract.

A blood test also provides information on the function of individual organs and the general state of health. However, there are no specific tumor markers in the blood for bladder cancer.

In addition, an ultrasound examination is usually performed to assess the kidneys and bladder. Any changes that may indicate a tumor can be detected.

If changes in the area of the bladder are detected during these steps, a tissue sample will thus be taken for examination (biopsy). This is the only way to determine whether it is actually a malignant tumor. For this purpose, a cystoscopy is performed. This is an endoscopic examination in which a thin, flexible tube, the so-called endoscope, is inserted through the urethra into the bladder under local anesthesia. With the endoscope, the doctor can scan the mucous membrane of the bladder for suspicious spots and take a tissue samples from the corresponding region. Subsequently, this tissue samples are examined histologically and only then will it be certain whether or not it is a cancer.

Determining the stage of the disease

If the histological finding confirms the suspicion and the diagnosis of bladder cancer is made, further examinations are usually necessary to determine at what stage of the disease the patient is at.

It is important to know how big the tumor is, where exactly it sits and how far it has spread. In medicine, this process is called staging. The stage of cancer must be precisely determined in order to determine the best possible treatment. The so-called TNM classification of the tumor is an important building block for determining the stage of the disease and choosing the optimal therapy. T stands for tumor size, N for the number of affected lymph nodes and M indicates whether daughter tumors (metastases) have formed in other organs.

To determine this, a computed tomography (CT) and magnetic resonance imaging (MRI) are performed as part of the staging. In these examinations, sectional images of the body are created. With these images, the radiologist can see where the tumor is and how large it is. These examinations provide important clues as to whether the tumor can be surgically removed. These examinations are completely painless and last between 20 and 40 minutes.

In some cases, a skeletal scintigram may be necessary to determine whether cancer cells have settled in the bone. The patient is injected with a low-level contrast agent into the vein, which accumulates in the bones. Special X-rays are then taken. In this way, bone metabolism can be assessed and possible tumor settlements can be detected.

Once all examinations have been completed, your doctor will tell you which stage of the disease you are at and what therapeutic steps can now be taken.

Treatment of bladder cancer

The possible treatments for bladder cancer are surgery, radiotherapy chemotherapy and cancer immunotherapy. Often these forms of therapy are also combined with each other.

Surgical removal of the tumor is usually an integral part of the treatments. If all cancer cells can be removed, there is the best chance of a complete cure. The type of procedure used depends primarily on the size of the tumor and the stage of the disease.

In combination with the removal of the tumor or with surgery, chemotherapy is often used to support the success of therapy. The goal of chemotherapy is to kill tumor cells. The drugs used (cytostatics) inhibit the growth of cancer cells and also directly damage them. You receive this treatment either by infusion into a vein, whereby the cytostatics can act systemically throughout the body, or by urinary bladder flushing directly into the bladder (local). Chemotherapy primarily attacks and harms tumor tissue, but unfortunately fast-growing, healthy cells are also affected. This can cause undesirable side effects. Ask your doctor what the side effects are and discuss with him or her the ways to alleviate them.

In certain cases, radiotherapy may be used as an alternative to surgery. The aim is also to destroy cancer cells and prevent the spread of the tumor. For this purpose, high-energy (ionizing) rays are directed at the tumor and attack the nucleus of the tumor cells, which means that they can no longer divide, and thus die. In this way, pain caused by the tumor or by metastases can also be alleviated, which often significantly improves the quality of life. Your doctor will inform you whether this form of therapy is appropriate for you and will inform you exactly about the course and possible side effects.

For cases in the advanced or metastatic stage, cancer immunotherapy offers new perspectives: These are substances (monoclonal antibodies) that inhibit certain factors on the surface of cancer cells and thus cause the immune system to target and destroy the cancer cells. Immunotherapies are administered intravenously and are usually performed on an outpatient basis. Depending on the active substance, the infusions are repeated every two to three weeks.

The right treatment for you

Which therapy is specifically available to you depends primarily on what type of bladder cancer you have been diagnosed with. Roughly, two types can be distinguished: on the one hand, the superficial, non-muscle invasive tumor, which is limited to the mucous membrane of the bladder, and on the other hand, the muscle-invasive tumor, which has spread in the muscle layer of the bladder wall. Muscle invasive tumors tend to spread to other neighboring organs. Treatment varies depending on the type of tumor.

In addition, the choice of optimal therapy depends on the stage of the disease you are in and how well your general health is.

Several physicians from various medical disciplines (urologist, surgeon, oncologist, radiation therapist) are involved in the planning of the exact therapy strategy. This collaboration of different experts is called a tumor board review in medicine. This ensures that all important factors are taken into account and that the optimal treatment options are found for you individually.

• Early-stage therapy

In the early stages of bladder cancer, the main focus is on the removal of the tumor. This is usually done by means of a so-called transurethral resection (TUR). This is an extended cystoscopy, i.e. the tumor can be gently removed via the urethra by means of an endoscope without the need for major surgery. The procedure is performed under anesthesia.

After the endoscopic treatment, the bladder is often rinsed with a chemotherapy drug. This is intended to destroy cancer cells that may remain in the bladder and to prevent further tumor growth.

• Therapy in the advanced stage of the disease

If it is an advanced tumor, endoscopic treatment is usually not sufficient. If the tumor has spread into the muscle wall of the bladder or has affected neighboring organs, major surgery is necessary. The removal of the bladder now offers the best chances of healing.

Along with the bladder, adjacent lymph nodes as well as possibly affected neighboring organs are also removed. In women, these can be the uterus, the ovaries, the fallopian tubes or parts of the vagina. In men, the prostate and seminal vesicles may need to be removed.

If the bladder needs to be removed, you will be informed in a conversation with your attending physician about how the function of your bladder can be replaced and what is most useful for you.

Systemic chemotherapy is often used before or after such surgery, either to reduce the size of the tumor in advance and thus facilitate the operation, or after the tumor has been removed in order to kill any remaining cancer cells or prevent re-growth of the tumor.

In certain cases, radiotherapy may be a possible alternative to surgery and preserve the bladder.

The effects of treatment

If a major surgery is required and the bladder needs to be removed, there are several ways to replace it.

For example, a replacement bladder can be formed from a small intestine piece, which is then connected to the ureters and the urethra. This makes almost natural urine excretion possible. However, this method can only be considered if the upper part of the urethra is not affected by the tumor.

If it is not possible to put a replacement bladder, the urine must be excreted through a newly created opening in the abdominal wall. This is called a so-called urostoma. There are various ways in which a urostoma is formed. For example, a piece of the small intestine can be used to form a reservoir that is connected on one side to the ureters and on the other side to the abdominal wall. The reservoir can be emptied by the person concerned via a catheter. In other cases, the ureter is directly connected to the skin.

A stoma changes the usual way of going to the toilet considerably. Urine excretion can no longer be controlled, it can take place practically at any time. The urine is collected in a bag and must be emptied regularly into the toilet. But even if the thought of it seems very stressful at first, in the end, even with Stoma, an almost normal everyday life is possible, there are only a few limitations. You can do sports, shower and bathe, even swimming is possible. A stoma can be hidden under a swimsuit, to prevent unpleasant looks. Special stoma consultants will train you in dealing with the stoma and help you.

Your doctor will inform you about the further consequences that the planned treatments may have for you and help you to get appropriate support.

In conclusion

The prognosis for the so-called “superficial” bladder cancer is generally excellent. The 5-year survival rate after treatment is in the range of 80% to 90%. But these tumors have a strong tendency to recur, hence the importance of close medical monitoring in all people with bladder cancer.

To put the odds in your favor, this periodic follow-up should be done for the rest of your life. Various medical examinations (cystoscopies and cytology) should be performed at regular intervals. These make it possible to quickly detect a recurrence of the tumor and to treat it as quickly as possible. This reduces the risk of the tumor becoming “invasive”, in which case the prognosis is less favorable.

There is hardly anyone who is not mentally and psychologically affected from the diagnosis of a cancer. Cancer is often is a source of mental stress and depression. In such a situation, it is important to seek help. Find a counselling center specializing in bladder cancer or a self-help group. People who have had the same or similar experiences can be of great help, and are often open for talks, complaints and problems about the common issue.