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Bladder Cancer

In Singapore, bladder cancer is the 7th most common cancer in both males and females. Men are affected 3 times more commonly than women. The causes for bladder cancer are ageing, chemical agents and cigarette smoking.

The most common presentation is painless gross haematuria (blood in the urine) [Fig 1]. It can also present with irritative bladder symptoms, like frequency of urination. Quite commonly, the diagnosis of bladder cancer is delayed because haematuria is intermittent or attributed to other causes eg. infection.

Diagnosis

a) Xray

Since haematuria can arise from any part of the urinary tract, the best initial investigation is a radiological test called an Intravenous Urogram (IVU). It involves the injection of contrast material into the vein which is then excreted by the kidneys to outline the urinary tract.

A bladder tumour may show up as a ‘filling defect’ if the tumour is large enough [Fig 2]. Sometimes, the bladder tumour can also be seen on an ultrasound examination if it is more than 1 cm. A negative IVU or ultrasound does not rule out bladder cancer as small ones < 1 cm may not be obvious. As such, a cystoscopy is mandatory for haematuria even if the IVU or ultrasound is reported as “normal”.

b) Cystoscopy

This is easily carried out under local anaesthesia in the clinic using a flexible instrument without causing much discomfort [Fig 3]. The advantage is that even small tumours can be seen. If so, a biopsy is taken to confirm if the bladder tumour is indeed cancerous as some 5% of bladder tumours may in fact be benign.

The urine can be sent for cytologic examination to look for presence of cancer cells. However, it is limited by low sensitivity (pick-up rate) and doctors generally do not advise this test be used alone in deciding whether a patient does or does not have cancer.

c) Cytology

The urine can be sent for cytologic examination to look for presence of cancer cells. However, it is limited by low sensitivity (< 50% pick-up rate) and doctors generally do not advise this test be used alone in deciding whether a patient does or does not have cancer.

Treatment

i) Early (superficial) Stage

a) Surgery

Once the diagnosis of a bladder lesion is confirmed, endoscopic surgery using a resectoscope instrument is needed, not only to surgically remove the tumour but also to stage it. General anesthesia is usually given and it may take up to 1 hour to resect the tumour. The pathologist then assesses the cancer according to its grade and the depth of invasion [Fig 4]. Biopsies of normal looking bladder are also done so as not to miss early tumours of the bladder lining (carcinoma-in-situ or CIS).

At the time of diagnosis, 80% of bladder tumours are superficial, i.e. confined to the bladder lining. The other 20% are invasive disease (invading the muscle layer of the bladder). Invasive tumours will eventually spread to the lymph nodes and distant organs, especially the lungs, bones and liver. Superficial tumours carry a good prognosis but do tend to recur frequently and may have a risk to becoming invasive in the future especially if the pathological grade is of the aggressive type or if carcinoma-in-situ is present. Prognosis for invasive disease is poor, hence it is important to treat bladder cancer at its early stage (stage 1) before it penetrates into the muscle layer.

After endoscopic tumour resection of superficial bladder tumours, periodic surveillance cystoscopies are needed to pick up recurrences, initially 3-monthly for the first year, then 6-monthly to yearly basis depending on the behaviour of the tumours. It is often said that bladder cancers may look the same but may not behave the same.

b) Chemotherapy

Those at high risk of recurrence, eg. multiple tumours, high-grade and those with carcinoma-in-situ (CIS) can be additionally treated with a choice of cytotoxic agents instilled into the bladder (intravesical therapy) to prevent recurrence. A typical treatment protocol would consist of weekly instillation for 6 weeks. The most common cytotoxic agent used is Mitomycin C. Immune-enhancing agent, BCG is superior and used for those whose tumours are likely to recur and those with CIS disease.

ii) Advanced (Invasive) Stage

a) Surgery

Treatment of patients with invasive bladder cancer has to be individualised according to the general status of health, extent of cancer and personal preferences. Complete surgical removal of the bladder (radical cystectomy) for muscle invasive cancer of the bladder provides the best chance of cure. Partial cystectomy is seldom done as most bladder tumours are of the transitional cell type and may recur in the remaining bladder. When a radical cystectomy type of operation is done, a procedure to divert the urine from the kidneys and ureters into a short segment of small bowel fashioned as an ileal conduit which appears as a stoma on the abdominal wall [Fig 5]. Urine is drained into an external collection bag (urostomy). This type of diversion remains the most popular as it is relatively easier and quick to construct. For younger patients, those who wish to remain continent or avoid a urostomy, it is possible to construct a “new bladder” using bowel which is reconnected to the native urethra in order that the patient can void normally. Although there is no need to wear an external bag, self intermittent catheterisation may be needed as such a neobladder may not empty well or get blocked with mucus. Nocturnal incontinence can also a problem. As such types of operations are more difficult and longer to perform, only motivated and fit, young patients are suitable candidates.

b) Radiotherapy

Although radiotherapy allows bladder conservation, the 5 year survival for patients with deeper muscle invasion is only 20%-40%.

The problem with radiotherapy is that it may not adequately kill the cancer cells and it has cumulative side-effects on the bladder and bowel, causing irritation and incontinence. It also has to be delivered daily for 6 weeks.

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