Every year in America, about 83,000 people are diagnosed with bladder cancer and about 17,000 people die of it, according to statistics from the American Cancer Society. But what exactly is bladder cancer, and who’s at risk?
“The urinary bladder is a muscular organ in the pelvis, just above and behind the public bone,” says Dr. Ming Yin, a medical oncologist and assistant professor of internal medicine at the Ohio State University Comprehensive Cancer Center — Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and the Ohio State University College of Medicine in Columbus. “The function of the bladder is to store and expel urine.”
What Is Bladder Cancer?
Bladder cancer, like all types of cancer, occurs when cells in the bladder begin to grow and divide uncontrollably.
Bladder cancer is the sixth most commonly occurring cancer in men, and the 17th in women. One reason why bladder cancer is among the more common cancers is because the bladder serves as a storage container for urine, says Dr. Andrew Hsieh, associate professor in the human biology division and the clinical research division at the Fred Hutchinson Cancer Research Center in Seattle.
“The inner lining of the bladder comes in contact with urine,” and toxins that are being removed from the body via urine can cause the cells to mutate and become cancerous. “These toxins are concentrated in your urine and your urine is sitting in your bladder for hours. So basically, it’s direct interaction between that urine (and the toxins in it) and the tissue that allows for mutations that occur” that can eventually become cancer in some people.
There are several factors that can increase your risk of developing bladder cancer, including:
— Chemical exposures.
— Infections and inflammation.
Dr. Shilpa Gupta, a bladder cancer specialist and director of the Cleveland Clinic’s genitourinary medical oncology program, says “smoking is the number one risk factor for bladder cancer.” While it’s common to think of smoking as increasing risk of lung cancer and heart disease, “your risk decreases after you stop smoking for a certain period of time. But for bladder cancer, that risk doesn’t go away,” Hsieh says.
The specific link between smoking and bladder cancer is that toxins from cigarette smoke wind up in the urine, and the cells inside the bladder come into contact with these toxins as urine accumulates.
Yin says that being male is a major risk factor for this type of cancer. “Of the 18,000 people diagnosed with bladder cancer every year in the United States, 75% to 80% are male.” The higher incident rates in men are believed to be connected to smoking — traditionally men have been more likely to smoke and smoke heavily than women.
Also, men traditionally have also had higher exposure to industrial chemicals that have been linked to bladder cancer.
Exposure to industrial chemicals, such as paint components, polycyclic aromatic hydrocarbons (PAHs) and diesel exhaust, as well as arsenic in drinking water can also elevate risk. Dr. Brian Norouzi, director of the urologic cancer program at Providence St. Joseph Hospital in Orange, California, notes that “there are many past environmental exposures, including older hair dyes and manufacturing projects that had been linked with a higher risk of bladder cancer.
I am certain there are more chemical exposures that we don’t even know about yet that may lead to a higher risk.” Hsieh notes that exposure to Agent Orange, a chemical defoliant used during the Vietnam War, appears to be linked to increased rates of bladder cancer in veterans of that conflict.
Infections and inflammation.
Chronic trauma, such as frequently having bladder stones, having had radiation treatments, recurrent urinary tract infections or catheterization can also increase the risk of developing bladder cancer. Though it’s not found in the United States, infection that comes from a parasite called schistosomiasis can cause bladder cancer, too, Hsieh notes.
Age is also a factor, given that bladder cancer tends to affect older adults more than younger adults. Yin says most patients with the disease are diagnosed in their late 60s or early 70s.
[Read: Anti-Cancer Foods.]
“Bladder cancer can be a relatively silent predator,” Norouzi says. Often, the only sign is blood in the urine. And this may not be visible to the naked eye, but rather microscopic and only detectable with a urinalysis.
To be sure, “blood in the urine does not mean bladder cancer,” Hsieh says. “But it can be associated with bladder cancer.” It could be a sign of an infection, a problem with the kidneys or the result of physical trauma, but it needs to be checked out, he says.
Norouzi says that bladder cancers are “rarely diagnosed by X-ray, although a CT scan can pick up some of them.” Instead, most bladder cancers are diagnosed by examination of the bladder by a fiber optic scope. This procedure, called cystoscopy, can be undertaken in the urologists office.
As with other forms of cancer, the earlier you can get a diagnosis the better, as the prognosis only worsens the longer the cancer has to grow unchecked. However, this can be challenging, Hsieh notes, because there’s no routine screening for bladder cancer like there is with some other cancers, such as colon, breast and prostate cancer.
Dr. Debasish Sundi, a urologist and assistant professor of urologic oncology with the Pelotonia Institute for Immuno-Oncology at the Ohio State University Comprehensive Cancer Center — Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and the Ohio State University College of Medicine in Columbus, says that the stage and characteristics of the tumor will determine how it’s treated.
“About 70% of patients have superficial bladder cancer, or so-called non-muscle-invasive bladder cancer,” Sundi says. This means that the tumors are primarily in the epithelium, or the thin, inner layer of cells that line the bladder and have not yet grown into the muscle below.
In these cancers, sometimes the urologist may be able to “scrape it off,” Gupta says. This procedure is called a resection. But because bladder cancer has “a high propensity to recur” patients must be monitored regularly, Norouzi says. This means the patient will need to undergo cystoscopy every three months to look for changes in the bladder lining.
In some cases, a treatment called BCG therapy, a type of intravesical immunotherapy for treating early stage bladder cancer, may be used. With this treatment, the medication is injected directly into the bladder via a short catheter. It stays in the bladder for up to two hours and “causes local inflammation in the area that’s actually good in fighting the cancer,” Hsieh says. BCG is “one of the oldest immunotherapies” and it’s been found useful for low-grade or early stage bladder cancer.
For the 30% or so of patients whose cancer has invaded the muscle wall — called muscle-invasive bladder cancer — and for those for whom the cancer has metastasized beyond the bladder to other parts of the body, such as the liver, lungs or bones, treatment may include surgery, radiation and/or chemotherapy.
“Chemotherapy is frequently administered prior to surgery to shrink the tumor size,” Yin says. This makes it easier for the surgeon to remove the tumor and removes any small cells that might not be visible on imaging scans.
In some cases where the cancer has invaded the muscle, patients may need to have the whole bladder removed. The body still needs to excrete urine, so depending on the specifics of the patient and the case, the surgeon may offer a procedure called a urostomy in which they create an opening, called a stoma, from inside the body and connect the tubes that carry urine to the bladder to an external pouch where it can drain off and be discarded.
In other cases, a new bladder is constructed from the patient’s own tissue. Sometimes, the new bladder is built from a section of the gut.
[Read: Types of Bladder Cancer]
Stage 4 Bladder Cancer Treatments
“If the tumor is already outside of the pelvis or even spreads to a distance organ, which is noted as stage 4, the bladder cancer is considered incurable, though still treatable,” Yin says.
For folks in this category, systemic therapies can be used to control tumor growth and prolong life, Sundi says. “Multiple treatment options are available that have substantially improved the clinical outcomes of stage 4 bladder cancer management.”
These treatments include:
— Chemotherapy. As with other types of cancer, drugs that kill fast-growing cells can help shrink bladder cancer tumors in some people.
— Immunotherapies. Immunotherapy drugs leverage the body’s own immune system to fight the cancer. “There’s a number of them,” Hsieh says, and these so-called checkpoint inhibitors turn off a chemical signal coming from the cancer cells that effectively helps it hide from the immune system. This makes the cancer cell visible, in a manner of speaking, to the immune cells that can destroy it. “I’d say about 10% to 15% of patients have had amazing response to this type of therapy,” he says. Gupta adds that certain immunotherapy drugs are now used as a maintenance treatment after a patient has had chemotherapy to maintain the tumor-shrinking response.
— Targeted therapies. These therapies “target a particular mutation” in the cancer cell, Gupta says. These precision medications have helped certain people with those mutations live longer.
— Antibody drug conjugates. These are “hybrid immunotherapies that deliver chemotherapy-like medication specifically to cancer cells,” Sundi explains.
The recent proliferation of medications had improved the odds of survival from this cancer, Hsieh says. For example, one of his patients, came in with metastatic bladder cancer that had invaded the liver and other organs. “This was about five years ago. I started her on the therapy about five years ago, and she’s still with us today. The therapy is just amazing,” he says.
Gupta adds that prior to the approval of immunotherapies to treat bladder cancer in 2016, “it was pretty much a death sentence because we hadn’t had any other treatments. Immunotherapy has really improved outcomes.”
And there’s more hope on the horizon as research continues and additional treatments come online. “It’s been really great to witness and be a part of this as I walk with patients through their disease,” Hsieh says. “For the first time, we’re able to offer quite significant hope that we can actually increase lifespan while maintaining quality of life.”
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