- The Bladder
- Understanding Cancer
- Bladder Cancer: Who's at Risk?
- Recognizing Symptoms
- Treatment for Bladder Cancer
- Side Effects of Cancer Treatment
The bladder is a hollow organ in the lower abdomen. It stores
urine, the liquid waste produced by the kidneys. Urine passes
from each kidney into the bladder through a tube called a
An outer layer of muscle surrounds the inner lining of the
bladder. When the bladder is full, the muscles in the bladder
wall can tighten to allow urination. Urine leaves the bladder
through another tube, the urethra.
Cancer is a group of many related diseases. All cancers begin
in cells, the body's basic unit of life. Cells make up tissues,
and tissues make up the organs of the body.
Normally, cells grow and divide to form new cells as the
body needs them. When cells grow old and die, new cells take
Sometimes this orderly process goes wrong. New cells form
when the body does not need them, and old cells do not die
when they should. These extra cells can form a mass of tissue
called a growth or tumor.
Tumors can be benign or malignant:
Benign tumors are not cancer.
Usually, doctors can remove them. Cells from benign tumors
do not spread to other parts of the body. In most cases, benign
tumors do not come back after they are removed. Most important,
benign tumors are rarely a threat to life.
Malignant tumors are cancer. They
are generally more serious. Cancer cells can invade and damage
nearby tissues and organs. Also, cancer cells can break away
from a malignant tumor and enter the bloodstream or the lymphatic
system. That is how cancer cells spread from the original
(primary) tumor to form new tumors in other organs. The spread
of cancer is called metastasis.
The wall of the bladder is lined with cells called transitional
cells and squamous cells. More than 90 percent of bladder
cancers begin in the transitional cells. This type of bladder
cancer is called transitional cell carcinoma. About 8 percent
of bladder cancer patients have squamous cell carcinomas.
Cancer that is only in cells in the lining of the bladder
is called superficial bladder cancer. The doctor might call
it carcinoma in situ. This type of bladder cancer often comes
back after treatment. If this happens, the disease most often
recurs as another superficial cancer in the bladder.
Cancer that begins as a superficial tumor may grow through
the lining and into the muscular wall of the bladder. This
is known as invasive cancer. Invasive cancer may extend through
the bladder wall. It may grow into a nearby organ such as
the uterus or vagina (in women) or the prostate gland (in
men). It also may invade the wall of the abdomen.
When bladder cancer spreads outside the bladder, cancer cells
are often found in nearby lymph nodes. If the cancer has reached
these nodes, cancer cells may have spread to other lymph nodes
or other organs, such as the lungs, liver, or bones.
When cancer spreads (metastasizes) from its original place
to another part of the body, the new tumor has the same kind
of abnormal cells and the same name as the primary tumor.
For example, if bladder cancer spreads to the lungs, the cancer
cells in the lungs are actually bladder cancer cells. The
disease is metastatic bladder cancer, not lung cancer. It
is treated as bladder cancer, not as lung cancer. Doctors
sometimes call the new tumor "distant" disease.
Bladder Cancer: Who's at Risk?
No one knows the exact causes of bladder cancer. However,
it is clear that this disease is not contagious. No one can
"catch" cancer from another person.
People who get bladder cancer are more likely than other
people to have certain risk factors. A risk factor is something
that increases a person's chance of developing the disease.
Still, most people with known risk factors do not get bladder
cancer, and many who do get this disease have none of these
factors. Doctors can seldom explain why one person gets this
cancer and another does not.
Studies have found the following risk factors for bladder
Age. The chance of getting bladder
cancer goes up as people get older. People under 40 rarely
get this disease.
Tobacco. The use of tobacco is
a major risk factor. Cigarette smokers are two to three times
more likely than nonsmokers to get bladder cancer. Pipe and
cigar smokers are also at increased risk.
Occupation. Some workers have
a higher risk of getting bladder cancer because of carcinogens
in the workplace. Workers in the rubber, chemical, and leather
industries are at risk. So are hairdressers, machinists, metal
workers, printers, painters, textile workers, and truck drivers.
Infections. Being infected with
certain parasites increases the risk of bladder cancer. These
parasites are common in tropical areas but not in the United
Treatment with cyclophosphamide
or arsenic. These drugs are used to treat cancer and some
other conditions. They raise the risk of bladder cancer.
Race. Whites get bladder cancer
twice as often as African Americans and Hispanics. The lowest
rates are among Asians.
Being a man. Men are two to three
times more likely than women to get bladder cancer.
Family history. People with family
members who have bladder cancer are more likely to get the
disease. Researchers are studying changes in certain genes
that may increase the risk of bladder cancer.
Personal history of bladder cancer.
People who have had bladder cancer have an increased chance
of getting the disease again.
Chlorine is added to water to make it safe to drink. It kills
deadly bacteria. However, chlorine by-products sometimes can
form in chlorinated water. Researchers have been studying
chlorine by-products for more than 25 years. So far, there
is no proof that chlorinated water causes bladder cancer in
people. Studies continue to look at this question.
Some studies have found that saccharin, an artificial sweetener,
causes bladder cancer in animals. However, research does not
show that saccharin causes cancer in people.
People who think they may be at risk for bladder cancer should
discuss this concern with their doctor. The doctor may suggest
ways to reduce the risk and can plan an appropriate schedule
Common symptoms of bladder cancer include:
- Blood in the urine (making the urine slightly rusty to
- Pain during urination, and
- Frequent urination, or feeling the need to urinate without
These symptoms are not sure signs of bladder cancer. Infections,
benign tumors, bladder stones, or other problems also can
cause these symptoms. Anyone with these symptoms should see
a doctor so that the doctor can diagnose and treat any problem
as early as possible. People with symptoms like these may
see their family doctor or a urologist, a doctor who specializes
in diseases of the urinary system.
If a patient has symptoms that suggest bladder cancer, the
doctor may check general signs of health and may order lab
tests. The person may have one or more of the following procedures:
Physical exam -- The doctor feels the abdomen and pelvis
for tumors. The physical exam may include a rectal or vaginal
Urine tests -- The laboratory checks the urine for blood,
cancer cells, and other signs of disease.
Intravenous pyelogram -- The doctor injects dye into a blood
vessel. The dye collects in the urine, making the bladder
show up on x-rays.
Cystoscopy -- The doctor uses a thin, lighted tube (cystoscope)
to look directly into the bladder. The doctor inserts the
cystoscope into the bladder through the urethra to examine
the lining of the bladder. The patient may need anesthesia
for this procedure.
The doctor can remove samples of tissue with the cystoscope.
A pathologist then examines the tissue under a microscope.
The removal of tissue to look for cancer cells is called a
biopsy. In many cases, a biopsy is the only sure way to tell
whether cancer is present. For a small number of patients,
the doctor removes the entire cancerous area during the biopsy.
For these patients, bladder cancer is diagnosed and treated
in a single procedure.
If bladder cancer is diagnosed, the doctor needs to know
the stage, or extent, of the disease to plan the best treatment.
Staging is a careful attempt to find out whether the cancer
has invaded the bladder wall, whether the disease has spread,
and if so, to what parts of the body.
The doctor may determine the stage of bladder cancer at the
time of diagnosis, or may need to give the patient more tests.
Such tests may include imaging tests -- CT scan, magnetic
resonance imaging (MRI), sonogram, intravenous pyelogram,
bone scan, or chest x-ray. Sometimes staging is not complete
until the patient has surgery.
These are the main features of each stage of the disease:
Stage 0 -- The cancer cells are found only on the surface
of the inner lining of the bladder. The doctor may call this
superficial cancer or carcinoma in situ.
Stage I -- The cancer cells are found deep in the inner lining
of the bladder. They have not spread to the muscle of the
Stage II -- The cancer cells have spread to the muscle of
Stage III -- The cancer cells have spread through the muscular
wall of the bladder to the layer of tissue surrounding the
bladder. The cancer cells may have spread to the prostate
(in men) or to the uterus or vagina (in women).
Stage IV -- The cancer extends to the wall of the abdomen
or to the wall of the pelvis. The cancer cells may have spread
to lymph nodes and other parts of the body far away from the
bladder, such as the lungs.
Treatment for Bladder Cancer
People with bladder cancer have many treatment options. They
may have surgery, radiation therapy, chemotherapy, or biological
therapy. Some patients get a combination of therapies.
The doctor is the best person to describe treatment choices
and discuss the expected results of treatment.
A patient may want to talk to the doctor about taking part
in a clinical trial, a research study of new treatment methods.
Clinical trials are an important option for people with all
stages of bladder cancer.
Surgery is a common treatment
for bladder cancer. The type of surgery depends largely on
the stage and grade of the tumor. The doctor can explain each
type of surgery and discuss which is most suitable for the
Transurethral resection: The doctor may treat early (superficial)
bladder cancer with transurethral resection (TUR). During
TUR, the doctor inserts a cystoscope into the bladder through
the urethra. The doctor then uses a tool with a small wire
loop on the end to remove the cancer and to burn away any
remaining cancer cells with an electric current. (This is
called fulguration.) The patient may need to be in the hospital
and may need anesthesia. After TUR, patients may also have
chemotherapy or biological therapy.
Radical cystectomy: For invasive bladder cancer, the most
common type of surgery is radical cystectomy. The doctor also
chooses this type of surgery when superficial cancer involves
a large part of the bladder. Radical cystectomy is the removal
of the entire bladder, the nearby lymph nodes, part of the
urethra, and the nearby organs that may contain cancer cells.
In men, the nearby organs that are removed are the prostate,
seminal vesicles, and part of the vas deferens. In women,
the uterus, ovaries, fallopian tubes, and part of the vagina
Segmental cystectomy: In some cases, the doctor may remove
only part of the bladder in a procedure called segmental cystectomy.
The doctor chooses this type of surgery when a patient has
a low-grade cancer that has invaded the bladder wall in just
Sometimes, when the cancer has spread outside the bladder
and cannot be completely removed, the surgeon removes the
bladder but does not try to get rid of all the cancer. Or,
the surgeon does not remove the bladder but makes another
way for urine to leave the body. The goal of the surgery may
be to relieve urinary blockage or other symptoms caused by
When the entire bladder is removed, the surgeon makes another
way to collect urine. The patient may wear a bag outside the
body, or the surgeon may create a pouch inside the body with
part of the intestine.
Radiation therapy (also called
radiotherapy) uses high-energy rays to kill cancer cells.
Like surgery, radiation therapy is local therapy. It affects
cancer cells only in the treated area.
A small number of patients may have radiation therapy before
surgery to shrink the tumor. Others may have it after surgery
to kill cancer cells that may remain in the area. Sometimes,
patients who cannot have surgery have radiation therapy instead.
Doctors use two types of radiation therapy to treat bladder
External radiation: A large machine outside the body aims
radiation at the tumor area. Most people receiving external
radiation are treated 5 days a week for 5 to 7 weeks as an
outpatient. This schedule helps protect healthy cells and
tissues by spreading out the total dose of radiation. Treatment
may be shorter when external radiation is given along with
Internal radiation: The doctor places a small container of
a radioactive substance into the bladder through the urethra
or through an incision in the abdomen. The patient stays in
the hospital for several days during this treatment. To protect
others from radiation exposure, patients may not be able to
have visitors or may have visitors for only a short period
of time while the implant is in place. Once the implant is
removed, no radioactivity is left in the body.
Some patients with bladder cancer receive both kinds of radiation
Chemotherapy uses drugs to kill
cancer cells. The doctor may use one drug or a combination
For patients with superficial bladder cancer, the doctor
may use intravesical chemotherapy after removing the cancer
with TUR. This is local therapy. The doctor inserts a tube
(catheter) through the urethra and puts liquid drugs in the
bladder through the catheter. The drugs remain in the bladder
for several hours. They mainly affect the cells in the bladder.
Usually, the patient has this treatment once a week for several
weeks. Sometimes, the treatments continue once or several
times a month for up to a year.
If the cancer has deeply invaded the bladder or spread to
lymph nodes or other organs, the doctor may give drugs through
a vein. This treatment is called intravenous chemotherapy.
It is systemic therapy, meaning that the drugs flow through
the bloodstream to nearly every part of the body. The drugs
are usually given in cycles so that a recovery period follows
every treatment period.
The patient may have chemotherapy alone or combined with
surgery, radiation therapy, or both. Usually chemotherapy
is an outpatient treatment given at the hospital, clinic,
or at the doctor's office. However, depending on which drugs
are given and the patient's general health, the patient may
need a short hospital stay.
Biological therapy (also called
immunotherapy) uses the body's natural ability (immune system)
to fight cancer. Biological therapy is most often used after
TUR for superficial bladder cancer. This helps prevent the
cancer from coming back.
The doctor may use intravesical biological therapy with BCG
solution. BCG solution contains live, weakened bacteria. The
bacteria stimulate the immune system to kill cancer cells
in the bladder. The doctor uses a catheter to put the solution
in the bladder. The patient must hold the solution in the
bladder for about 2 hours. BCG treatment is usually done once
a week for 6 weeks.
Side Effects of Cancer Treatment
Because cancer treatment may damage healthy cells and tissues,
unwanted side effects sometimes occur. These side effects
depend on many factors, including the type and extent of the
treatment. Side effects may not be the same for each person,
and they may even change from one treatment session to the
next. Doctors and nurses will explain the possible side effects
of treatment and how they will help the patient manage them.
For a few days after TUR, patients may have some blood in
their urine and difficulty or pain when urinating. Otherwise,
TUR generally causes few problems.
After cystectomy, most patients are uncomfortable during
the first few days. However, medicine can control the pain.
Patients should feel free to discuss pain relief with the
doctor or nurse. Also, it is common to feel tired or weak
for a while. The length of time it takes to recover from an
operation varies for each person.
After segmental cystectomy, patients may not be able to hold
as much urine in their bladder as they used to, and they may
need to urinate more often. In most cases, this problem is
temporary, but some patients may have long-lasting changes
in how much urine they can hold.
If the surgeon removes the bladder, the patient needs a new
way to store and pass urine. In one common method, the surgeon
uses a piece of the person's small intestine to form a new
tube through which urine can pass. The surgeon attaches one
end of the tube to the ureters and connects the other end
to a new opening in the wall of the abdomen. This opening
is called a stoma. A flat bag fits over the stoma to collect
urine, and a special adhesive holds it in place. The operation
to create the stoma is called a urostomy or an ostomy.
For some patients, the doctor is able to use a part of the
small intestine to make a storage pouch (called a continent
reservoir) inside the body. Urine collects in the pouch instead
of going into a bag. The surgeon connects the pouch to the
urethra or to a stoma. If the surgeon connects the pouch to
a stoma, the patient uses a catheter to drain the urine.
Bladder cancer surgery may affect a person's sexual function.
Because the surgeon removes the uterus and ovaries in a radical
cystectomy, women are not able to get pregnant. Also, menopause
occurs at once. Hot flashes and other symptoms of menopause
caused by surgery may be more severe than those caused by
natural menopause. Many women take hormone replacement therapy
(HRT) to relieve these problems. If the surgeon removes part
of the vagina during a radical cystectomy, sexual intercourse
may be difficult.
In the past, nearly all men were impotent after radical cystectomy,
but improvements in surgery have made it possible for some
men to avoid this problem. Men who have had their prostate
gland and seminal vesicles removed no longer produce semen,
so they have dry orgasms. Men who wish to father children
may consider sperm banking before surgery or sperm retrieval
It is natural for a patient to worry about the effects of
bladder cancer surgery on sexuality. Patients may want to
talk with the doctor about possible side effects and how long
these side effects are likely to last. Whatever the outlook,
it may be helpful for patients and their partners to talk
about their feelings and help one another find ways to share
intimacy during and after treatment.
The side effects of radiation therapy depend mainly on the
treatment dose and the part of the body that is treated. Patients
are likely to become very tired during radiation therapy,
especially in the later weeks of treatment. Resting is important,
but doctors usually advise patients to try to stay as active
as they can.
External radiation may permanently darken or "bronze"
the skin in the treated area. Patients commonly lose hair
in the treated area and their skin may become red, dry, tender,
and itchy. These problems are temporary, and the doctor can
suggest ways to relieve them.
Radiation therapy to the abdomen may cause nausea, vomiting,
diarrhea, or urinary discomfort. The doctor can suggest medicines
to ease these problems.
Radiation therapy also may cause a decrease in the number
of white blood cells, cells that help protect the body against
infection. If the blood counts are low, the doctor or nurse
may suggest ways to avoid getting an infection. Also, the
patient may not get more radiation therapy until blood counts
improve. The doctor will check the patient's blood counts
regularly and change the treatment schedule if it is necessary.
For both men and women, radiation treatment for bladder cancer
can affect sexuality. Women may experience vaginal dryness,
and men may have difficulty with erections.
Although the side effects of radiation therapy can be distressing,
the doctor can usually treat or control them. It also helps
to know that, in most cases, side effects are not permanent.
The side effects of chemotherapy depend mainly on the drugs
and the doses the patient receives as well as how the drugs
are given. In addition, as with other types of treatment,
side effects vary from patient to patient.
Anticancer drugs that are placed in the bladder cause irritation,
with some discomfort or bleeding that lasts for a few days
after treatment. Some drugs may cause a rash when they come
into contact with the skin or genitals.
Systemic chemotherapy affects rapidly dividing cells throughout
the body, including blood cells. Blood cells fight infection,
help the blood to clot, and carry oxygen to all parts of the
body. When anticancer drugs damage blood cells, patients are
more likely to get infections, may bruise or bleed easily,
and may have less energy. Cells in hair roots and cells that
line the digestive tract also divide rapidly. As a result,
patients may lose their hair and may have other side effects
such as poor appetite, nausea and vomiting, or mouth sores.
Usually, these side effects go away gradually during the recovery
periods between treatments or after treatment is over.
Certain drugs used in the treatment of bladder cancer also
may cause kidney damage. To protect the kidneys, patients
need a lot of fluid. The nurse may give the patient fluids
by vein before and after treatment. Also, the patient may
need to drink a lot of fluids during treatment with these
Certain anticancer drugs can also cause tingling in the fingers,
ringing in the ears, or hearing loss. These problems may go
away after treatment stops.
BCG therapy can irritate the bladder. Patients may feel an
urgent need to urinate, and may need to urinate frequently.
Patients also may have pain, especially when urinating. They
may feel tired. Some patients may have blood in their urine,
nausea, a low-grade fever, or chills.