Bladder Cancer
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Background
Bladder cancer is the 7th most common cancer to be diagnosed in the UK (1). Every year approximately 10,300 people are diagnosed with bladder cancer, and almost 60% of those diagnosed are 75 years old and older (2).
Men are 3-4 times more likely to be diagnosed with bladder cancer compared to women (1)
There are two types of bladder cancer (1):
- Non-muscle invasive (accounting for 75-80% of cases)
- Muscle invasive
Risk Factors for bladder cancer include:
- Tabacco Smoking (3)
- Occupational exposure to aromatic amines, polycyclic aromatic hydrocarbons and chlorinated hydrocarbons, which can be found in industrial plants which processes paints, dyes, metal and petroleum products (3)
- For muscle invasive bladder cancer bladder schistosomiasis is also a risk factor. This is a parasitic infection, second only in incidence to malaria. It is commonly found in Africa, Asia, South America, and the Caribbean (4).
Presentation
Signs and symptoms (5,6):
- Most common presentation is painless, visible haematuria.
- Other lower urinary tract symptoms, particularly voiding issues could also indicate bladder cancer.
- More advanced tumours may also present with pelvic pain and urinary tract obstruction.
Management
Diagnosis
Patients could be offered a range of diagnostic tests including
- Cystoscopy (a camera test that is done transurethral) and biopsies (6)
- Urine cytology (particularly useful for higher grade tumours) (5)
- CT, for distant disease or pelvic MRI staging for local nodes (particularly if muscle invasive bladder cancer is suspected at cystoscopy) (1)
Staging
Bladder cancer staging uses the TNM classification.
Bladder cancer is also given a grade according to it’s histology.
2017 TNM classification of urinary bladder cancer (taken and adapted from (6)):
| T - Primary Tumour | |
|---|---|
| TX | Primary tumour cannot be assessed |
| T0 | No evidence of primary tumour |
| Ta | Non-invasive papillary carcinoma |
| Tis | Carcinoma in situ: ‘flat tumour’ |
| T1 | Tumour invades subepithelial connective tissue |
| T2 | Tumour invades muscle |
| --- T2a | Tumour invades superficial muscle (inner half) |
| --- T2b | Tumour invades deep muscle (outer half) |
| T3 | Tumour invades perivesical tissue |
| --- T3a | Microscopically |
| --- T3b | Macroscopically (extravesical mass) |
| T4 | Tumour invades any of the following: prostate stroma, seminal vesicles, uterus, vagina pelvic wall, abdominal wall |
| --- T4a | Tumour invades prostate stroma, seminal vesicles, uterus or vagina |
| --- T4b | Tumour invades pelvic wall or abdominal wall |
| N - Regional Lymph Nodes | |
|---|---|
| NX | Regional lymph nodes cannot be assessed |
| N0 | No regional lymph node metastasis |
| N1 | Metastasis in a single lymph node in the true pelvis (hypogastric, obturator, external iliac, or presacral) |
| N2 | Metastasis in multiple regional lymph nodes in the true pelvis (hypogastric, obturator, external iliac, or presacral) |
| N3 | Metastasis in common iliac lymph node(s) |
| M - Distant Metastasis | |
|---|---|
| M0 | No distant metastasis |
| M1a | Non-regional lymph nodes |
| M1b | Other distant metastasis |
Treatment Options
The management offered to the patient is based on the staging of the bladder cancer.
Having established that the patient has non-muscle invasive bladder cancer from the TNM staging, patients with non-muscle invasive bladder cancer are further divided into low, intermediate and high risk groups according to the tumour grading (1).
- All patients are offered a transurethral resection of the bladder tumour (TURBT).
- Patients in the intermediate-risk group are offered a course of at least six intravesical mitomycin C.
- High risk patients are also offered:
- Another TURBT within six weeks if the first one failed
- Intravesical Bacille Calmette-Guérin OR radical cystectomy
Follow up:
- Low risk – cystoscopy at 3 months and 12 months
- Intermediate risk – cystoscopy at 3, 9 and 18 months. Yearly thereafter, then discharge once 5 years disease free
- High risk – for those having not had a cystectomy offer cystoscopy every 3 months for 2 years, then every 6 months for 2 years, then once a year thereafter.
When it is suitable for the patient the options are:
- Neoadjuvant chemotherapy (cisplatin combination regime).
- ONE of either…
- a) Radical cystectomy. Patients are offered either a urinary stoma, or a continent urine diversion such as bladder substitution or catheterisable reservoir OR
- b) Radical radiotherapy (using a combination such as mitomycin with fluorouracil).
- Adjuvant chemotherapy if required
Follow up:
- Following radical cystoscopy, monitoring requirements are:
- annual imaging for hydronephrosis, stones or cancer
- annual eGFR, B12 + folate, metabolic acidosis
- CT chest, abdomen, and pelvis at 6, 12 and 24 months for evidence of local or distant recurrence.
- After radical radiotherapy treatment where the bladder is sparred:
- cystoscopy every 3 months for 2 years, then every 6 months for 2 years, then every year.
- Upper urinary tract imaging every 5 yeast
- CT chest, abdomen, and pelvis at 6, 12 and 24 months for evidence of local or distant recurrence
For patient with more advanced muscle invasive bladder cancer and patients with metastatic disease chemotherapy, immunotherapy, and treatments targeting specific molecular changes are the treatment options (7).
Guidelines
European Association of Urology: Non-muscle-invasive Bladder Cancer – https://uroweb.org/guidelines/non-muscle-invasive-bladder-cancer/chapter/introduction
European Association of Urology: Muscle-invasive and Metastatic Bladder Cancer – https://uroweb.org/guidelines/muscle-invasive-and-metastatic-bladder-cancer/chapter/diagnostic-evaluation
NICE guidelines – Bladder cancer: diagnosis and management (2015) – https://www.nice.org.uk/guidance/ng2
References
- Overview | Bladder cancer: diagnosis and management | Guidance | NICE [Internet]. NICE; 2015 [cited 2024 May 14]. Available from: https://www.nice.org.uk/guidance/ng2
- What is bladder cancer? [Internet]. [cited 2024 May 15]. Available from: https://www.cancerresearchuk.org/about-cancer/bladder-cancer/about
- Uroweb – European Association of Urology [Internet]. [cited 2024 May 15]. EPIDEMIOLOGY and AETIOLOGY – Uroweb. Available from: https://uroweb.org/guidelines/non-muscle-invasive-bladder-cancer/chapter/epidemiology-aetiology-and-pathology
- Uroweb – European Association of Urology [Internet]. [cited 2024 May 15]. EAU Guidelines on MIBC – EPIDEMIOLOGY AETIOLOGY AND PATHOLOGY – Uroweb. Available from: https://uroweb.org/guidelines/muscle-invasive-and-metastatic-bladder-cancer/chapter/epidemiology-aetiology-and-pathology
- Uroweb – European Association of Urology [Internet]. [cited 2024 May 21]. EAU Guidelines on MIBC – DIAGNOSTIC EVALUATION – Uroweb. Available from: https://uroweb.org/guidelines/muscle-invasive-and-metastatic-bladder-cancer/chapter/diagnostic-evaluation
- Uroweb – European Association of Urology [Internet]. [cited 2024 May 21]. DIAGNOSIS – Uroweb. Available from: https://uroweb.org/guidelines/non-muscle-invasive-bladder-cancer/chapter/diagnosis
- Uroweb – European Association of Urology [Internet]. [cited 2024 May 21]. EAU Guidelines on MIBC – DISEASE MANAGEMENT – Uroweb. Available from: https://uroweb.org/guidelines/muscle-invasive-and-metastatic-bladder-cancer/chapter/disease-management