Bladder cancer

Information from PDQ for patients [for physicians]

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PDQ is a computer system that gives up-to-date information on cancer and its prevention, detection, treatment, and supportive care. It is a service of the National Cancer Institute (NCI) for people with cancer and their families and for doctors, nurses, and other health care professionals.

To ensure that it remains current, the information in PDQ is reviewed and updated each month by experts in the fields of cancer treatment, prevention, screening, and supportive care. PDQ also provides information about research on new treatments (clinical trials), doctors who treat cancer, and hospitals with cancer programs. The treatment information in this summary is based on information in the PDQ summary for health professionals on this cancer.

How to use PDQ

PDQ can be used to learn more about current treatment of different kinds of cancer. You may find it helpful to discuss this information with your doctor, who knows you and has the facts about your disease. PDQ can also provide the names of additional health care professionals who specialize in treating patients with cancer.

Before you start treatment, you also may want to think about taking part in a clinical trial. PDQ can be used to learn more about these trials. A clinical trial is a research study that attempts to improve current treatments or finds information on new treatments for patients with cancer. Clinical trials are based on past studies and information discovered in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help patients with cancer. Information is collected about new treatments, their risks, and how well they do or do not work. When clinical trials show that a new treatment is better than the treatment currently used as "standard" treatment, the new treatment may become the standard treatment. Listings of current clinical trials are available on PDQ. Many cancer doctors who take part in clinical trials are listed in PDQ.

To learn more about cancer and how it is treated, or to learn more about clinical trials for your kind of cancer, call the National Cancer Institute's Cancer Information Service. The number is 1-800-4-CANCER (1-800-422-6237); TTY at 1-800-332-8615. The call is free and a trained information specialist will be available to answer cancer-related questions.

PDQ is updated whenever there is new information. Check with the Cancer Information Service to be sure that you have the most up-to-date information.

DESCRIPTION

What is cancer of the bladder?

Bladder cancer is a disease in which cancer (malignant) cells are found in the bladder. The bladder, a hollow organ in the lower part of the abdomen, stores urine. It is shaped like a small balloon, and it has a muscular wall that allows it to get larger or smaller. Urine is the liquid waste that is made by the kidneys when they clean the blood. The urine passes from the two kidneys into the bladder through two tubes called ureters. When the bladder is emptied during urination, the urine goes from the bladder to the outside of the body through another tube called the urethra.

A doctor should be seen if any of the following symptoms appear: blood in the urine (urine that looks bright red or rusty), pain during urination, passing urine often, or feeling the need to urinate but nothing comes out.

If there are symptoms, a doctor may use several tests to see if cancer of the bladder exists. A urine sample may be sent to a laboratory for tests to see if any cancer cells are present. The doctor may also do an internal examination by inserting gloved fingers into the vagina and/or rectum to feel for lumps. The doctor may then order a special x-ray called an intravenous pyelogram (IVP). For this x-ray, a special dye containing iodine is given through a needle inserted into a vein. The dye then goes into the urine, making the bladder easier to see on the x-rays. The patient may feel warm as the dye is given.

A doctor may also look directly into the bladder with a thin lighted tube called a cystoscope. The cystoscope is inserted into the bladder through the urethra. If tissue that is not normal is found, the doctor will need to cut out a small piece of this tissue and look at it under the microscope to see if there are any cancer cells. This procedure is called a biopsy. Other special x-rays may also be done to help diagnose cancer of the bladder.

The chance of recovery (prognosis) and choice of treatment depend on the stage of the cancer (whether it is just in the lining of the bladder or has spread to other places in the body) and the patient's general state of health.

STAGE EXPLANATION

Stages of cancer of the bladder

Once cancer of the bladder has been diagnosed, more tests will be done to find out if cancer cells have spread to other parts of the body (staging). To plan treatment, a doctor needs to know the stage of the disease. The following stages are used for cancer of the bladder:

Stage 0 or carcinoma in situ

Stage 0 is very early cancer. The cancer is found only on the inner lining of the bladder. After the cancer is taken out, no swelling or lumps are felt during an internal examination.

Stage I

Cancer cells have spread a little deeper into the inner lining of the bladder but have not spread to the muscular wall of the bladder.

Stage II

Cancer cells have spread to the inside lining of the muscles lining the bladder.

Stage III

Cancer cells have spread throughout the muscular wall of the bladder, to the layer of tissue surrounding the bladder and/or to the nearby reproductive organs. A doctor may feel for swelling or lumps after a patient has had an operation to take out the cancer.

Stage IV

Cancer cells have spread to the wall of the abdomen or pelvis or to the lymph nodes in the area. (Lymph nodes are small, bean-shaped structures that are found throughout the body; they produce and store infection-fighting cells.) The cancer may have also spread to lymph nodes and other parts of the body far away from the bladder.

Recurrent

Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the original place or in another part of the body.

TREATMENT OPTION OVERVIEW

How cancer of the bladder is treated

There are treatments for all patients with cancer of the bladder. Four kinds of treatment are used: - surgery (taking out the cancer in an operation) - radiation therapy (using high-dose x-rays or other high-energy rays to kill cancer cells and shrink tumors) - chemotherapy (using drugs to kill cancer cells) - biological therapy (using the body's immune system to fight cancer)

A new type of treatment called photodynamic therapy is being tested in clinical trials.

Surgery is a common treatment of cancer of the bladder. A doctor may take out the cancer using one of the following operations:

Transurethral resection is an operation that uses a cystoscope inserted into

the bladder through the urethra. The doctor then uses a tool with a small

wire loop on the end to remove the cancer or to burn the tumor away with high-energy electricity (fulguration).

Segmental cystectomy is an operation to take out the part of the bladder

where the cancer is found. Because bladder cancer often occurs in more than

one part of the bladder, this operation is used only in selected cases where the cancer is in one area.

Cystectomy is an operation to take out the bladder.

Radical cystectomy is an operation to take out the bladder and the tissue

around it. In women, the uterus, ovaries, fallopian tubes, part of the

vagina, and urethra are also removed. In men, the prostate and the glands

that produce fluid that is part of the semen (seminal vesicles) are also

removed, and the urethra may be removed as well. The lymph nodes in the pelvis may also be taken out (pelvic lymph node dissection).

Urinary diversion is an operation to make a way for urine to pass out of the

body so that it does not go through the bladder. It is used to relieve bladder symptoms when the tumor has spread.

If the bladder is removed, a doctor will need to make a new way for the body to store and pass urine. There are several ways to do this. Sometimes a doctor will use part of the small intestine to make a tube through which urine can pass out of the body through an opening (stoma) on the outside of the body. This procedure is sometimes called an ostomy or urostomy.

If a patient has an ostomy, a special bag to collect urine will need to worn. This special bag, which sticks to the skin around the stoma with a special glue, can be thrown away after it is used. The bag does not show under clothing and most people take care of these bags themselves. The doctor may also use part of the small intestine to make a new storage pouch (a continent reservoir) inside the body where urine can collect. A patient would then need to use a tube (catheter) to drain the urine through the stoma. Newer methods use a part of the small intestine to make a new storage pouch that is connected to the remaining part of the urethra if it has not been removed. Urine then passes out of the body through the urethra, and a stoma is not necessary.

Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy may be taken by pill, or it may be put in the body through a needle inserted into a vein or muscle. Chemotherapy is called a systemic treatment because the drug enters the bloodstream, travels through the body, and can kill cancer cells outside the bladder. Chemotherapy may also be given in a fluid that is put into the bladder through a tube going through the urethra (intravesical chemotherapy).

If a doctor removes all the cancer that can be seen at the time of the operation, a patient may be given chemotherapy after surgery to kill any cancer cells that are left. Chemotherapy given after an operation to a person who has no cancer cells that can be seen is called adjuvant chemotherapy. For bladder cancer, chemotherapy is sometimes given before surgery to try to improve results or to preserve the bladder. Chemotherapy given in this manner is called neoadjuvant chemotherapy. Neoadjuvant chemotherapy is being carefully studied in a clinical trial sponsored by the National Cancer Institute.

Radiation therapy uses high-energy x-rays to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external radiation therapy) or from putting materials that produce radiation (radioisotopes) through thin plastic tubes in the area where the cancer cells are found (internal radiation therapy).

Biological therapy tries to get the body to fight cancer. It uses materials made by the body or made in a laboratory to boost, direct, or restore the body's natural defenses against disease. Biological therapy is sometimes called biological response modifier (BRM) therapy or immunotherapy. Biological therapy may be given in a fluid that is put into the bladder through a tube going through the urethra (intravesical biological therapy).

Photodynamic therapy is a new type of treatment that uses special drugs and light to kill cancer cells. A drug that makes cancer cells more sensitive to light is put into the bladder, and a special light is used to shine on the bladder. This therapy is being studied for early stages of bladder cancer.

Treatment by stage

Treatment of cancer of the bladder depends on the stage of the disease, the type of disease, and the patient's age and overall condition.

Standard treatment may be considered, based on its effectiveness in patients in past studies, or participation in a clinical trial. Not all patients are cured with standard therapy, and some standard treatments may have more side effects than are desired. For these reasons, clinical trials are designed to find better ways to treat cancer patients and are based on the most up-to-date information. Clinical trials are ongoing in most parts of the country for most stages of cancer of the bladder. For more information, call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237); TTY at 1-800-332-8615.

STAGE 0 BLADDER CANCER

Treatment may be one of the following:

1. Removal of the cancer using a cystoscope inserted through the urethra to cut out the tumor and burn away any remaining cancer cells (transurethral resection with fulguration).
2. Transurethral resection with fulguration followed by intravesical BCG (bacillus Calmette-Guerin).
3. Transurethral resection with fulguration followed by intravesical chemotherapy.
4. Surgery to remove part of the bladder (segmental cystectomy).
5. Surgery to remove the whole bladder and organs around it (radical cystectomy).
6. A clinical trial of photodynamic therapy.
7. A clinical trial of intravesical biological therapy.
8. After treatment for the cancer, a patient may be given agents to prevent the cancer from coming back.

STAGE I BLADDER CANCER

Treatment may be one of the following:

1. Removal of the cancer using a cystoscope inserted through the urethra to cut out the tumor and burn away any remaining cancer cells (transurethral resection with fulguration).
2. Transurethral resection with fulguration followed by intravesical BCG (bacillus Calmette-Guerin).
3. Transurethral resection with fulguration followed by intravesical chemotherapy.
4. Surgery to remove part of the bladder (segmental cystectomy).
5. Surgery to remove the whole bladder and organs around it (radical cystectomy).
6. Internal radiation therapy with or without external-beam radiation therapy.
7. A clinical trial of agents to prevent the cancer from coming back after a patient has been treated for cancer.
8. A clinical trial of intravesical therapy.

STAGE II BLADDER CANCER

Treatment may be one of the following:

1. Surgery to remove the whole bladder and the organs around it (radical cystectomy). The lymph nodes in the pelvis may also be removed (lymph node dissection).
2. External-beam radiation therapy alone.
3. Internal radiation therapy before or after external-beam radiation therapy.
4. Removal of the cancer using a cystoscope inserted through the urethra to cut out the tumor and burn away any remaining cancer cells (transurethral resection with fulguration).
5. Surgery to remove part of the bladder (segmental cystectomy).
6. Clinical trials of systemic chemotherapy before cystectomy (neoadjuvant chemotherapy) or after cystectomy (adjuvant chemotherapy).
7. A clinical trial of systemic chemotherapy plus radiation therapy.

STAGE III BLADDER CANCER

Treatment may be one of the following:

1. Radical cystectomy. The lymph nodes in the pelvis may also be removed (pelvic lymph node dissection).
2. External radiation therapy.
3. External-beam and internal radiation therapy.
4. Surgery to remove part of the bladder (segmental cystectomy).
5. External-beam radiation and chemotherapy.
6. A clinical trial of systemic chemotherapy before cystectomy (neoadjuvant chemotherapy) or after cystectomy (adjuvant chemotherapy).
7. A clinical trial of chemotherapy and radiation therapy to keep the bladder.

STAGE IV BLADDER CANCER

If a patient has stage IV bladder cancer that has spread to nearby tissue or lymph nodes, but not to other parts of the body, treatment may be one of the following:

1. Radical cystectomy.
2. External-beam radiation therapy.
3. Surgery to make a way for urine to flow out of the body so that it does not go into the bladder (urinary diversion), to reduce symptoms.
4. Surgery to remove the bladder (cystectomy) to relieve symptoms.
5. Systemic chemotherapy by itself or in addition to surgery.
6. A clinical trial of systemic chemotherapy before cystectomy (neoadjuvant chemotherapy) or after cystectomy (adjuvant chemotherapy).
7. A clinical trial of chemotherapy and radiation therapy to keep the bladder.

If the cancer is found in lymph nodes or other places far away from the bladder, treatment may be one of the following:

1. External-beam radiation therapy.
2. Surgery to make a way for urine to pass out of the body without going through the bladder (urinary diversion) to reduce symptoms.
3. Surgery to remove the bladder (cystectomy) and to make a urinary diversion to reduce symptoms.
4. Systemic chemotherapy alone or in addition to surgery.
5. A clinical trial of chemotherapy.

RECURRENT BLADDER CANCER

If cancer comes back only in the bladder, treatment may be surgery, chemotherapy, or radiation therapy, depending on what treatment the patient received when cancer first appeared. If the cancer comes back following surgery to remove all of the bladder, a patient may receive chemotherapy. A patient may also choose to participate in a clinical trial.

TO LEARN MORE

TO LEARN MORE..... CALL 1-800-4-CANCER

To learn more about cancer of the bladder, call the National Cancer Institute's Cancer Information Service at 1-800-4-CANCER (1-800-422-6237); TTY at 1-800-332-8615. By dialing this toll-free number, a trained information specialist can help answer your questions.

The Cancer Information Service also has a variety of booklets that are available to the public on request. The following booklet about bladder cancer may be helpful:

What You Need To Know About Bladder Cancer

The following general booklets on questions related to cancer may also be helpful:

What You Need To Know About Cancer

Taking Time: Support for People with Cancer and the People Who Care About Them

What Are Clinical Trials All About?

Chemotherapy and You: A Guide to Self-Help During Treatment

Radiation Therapy and You: A Guide to Self-Help During Treatment

Eating Hints for Cancer Patients

Advanced Cancer: Living Each Day When Cancer Recurs: Meeting the Challenge Again

There are many other places where people can get materials and information about cancer treatment and services. The social service office at a hospital can be checked for local and national agencies that help with getting information about finances, getting to and from treatment, getting care at home, and dealing with problems.

For more information from the National Cancer Institute, please write to this address:

Date Last Modified: 02/1999

If you want to know more about cancer and how it is treated, or if you if you wish to know about clinical trials for your type of cancer, you can call the NCI's Cancer Information Service at 1-800-422-6237, toll free. A trained information specialist can talk with you and answer your questions.