Bladder cancer is the seventh most commonly diagnosed cancer in men worldwide, which drops to the eleventh when both genders are considered. Here, leading urologist Mr Ammar Alanbuki explains how bladder cancer can be detected early, the different stages and survival rates of the disease.
How can bladder cancer be detected early?
You will require a two-week-wait haematuria clinic referral if you are aged 45 or above and have unexplained visible blood in the urine (haematuria) in the absence of a urinary tract infection (UTI) or visible haematuria that persists or recurs after successful treatment of a UTI.
In addition, all patients aged 60 or above with unexplained symptomatic (dysuria) non-visible haematuria or have recurrent UTI should also be considered for a two-week-wait haematuria clinic.
The doctor will take a comprehensive history, which includes smoking (accounts for 50% of cases) or exposure to tobacco smoke. It is important to also take your occupational history, such as exposure to aromatic amines or polycyclic aromatic hydrocarbons and chlorinated hydrocarbons, which occur in paint, dye, metal and petroleum industries, and additionally if there has been exposure to hair dye or ionizing radiation.
Other risk factors include previous schistosomiasis infection or a family history of bladder cancer.
What tests will the urologist make to determine if it's cancer and the stage it's reached?
There will be a thorough examination, which includes checking your blood pressure, body mass index (BMI), full abdominal and pelvic examination.
Investigations may involve MSU (sending urine for culture), urine for cytology, routine bloodwork, an ultrasound scan for assessment of upper tract (kidneys) and a flexible cystoscopy (camera exam of the urethra and bladder). Other investigations may require a CT urogram in highly suspicious cases and urinary markers.
If a mass is found during flexible cystoscopy, then the patient should be counselled for transurethral resection of bladder tumour (TURBT) under general anaesthesia, which is the way to give a diagnosis and staging for cancer (+/- staging CT).
What are the stages of bladder cancer?
The stage of cancer tells a specialist how big the cancer is and whether it has spread, and it will also determine your treatment plan.
Doctors follow the TNM staging system, which stands for Tumour, Node and Metastasis. TNM staging for bladder cancer is as follows:
T: Primary tumour
Tx: Primary tumour can't be assessed
T0: No evidence of primary tumour
Ta: Non-invasive papillary carcinoma (localised to the innermost layer of the bladder lining)
Tis: Very early, high-grade cancer cells are only in the bladder lining
T1: Tumour invades subepithelial connective tissue
T2: Tumour invades muscle layer:
-T2a: Invades the inner half
-T2b: Invades the outer half
T3: Tumour invades the perivesical tissue, which is the fat layer:
-T3a: Can only be seen microscopically
-T3b: Can be seen macroscopically
T4: Tumour invades the surrounding structures outside the bladder:
-T4a: Prostate, seminal vesicles, uterus or vagina.
-T4b: Pelvic wall or abdominal wall.
N - Regional lymph nodes
Nx: Regional lymph nodes can't be assessed
N0: No regional lymph node metastases
-N1: Metastases in a single lymph node in the pelvis which is between your hip bones
-N2: Metastases in multiple regional lymph nodes in the pelvis
-N3: Metastases in common iliac nodes, meaning there are cancer cells just outside the pelvis
Metastases (M) - which describes whether cancer has spread throughout the body
M- Distant metastases
M0: No distance metastases
M1a: Non-regional lymph nodes
M1b: Other distant metastases
What are the treatment options for bladder cancer?
Treatment options will depend on the stage of cancer.
Non-muscle invasive bladder cancer:
1. Low-risk cancer (solitary lesion G1/2 low grade, Ta tumour and 3cm or less )
- Treatment: TURBT + single dose intravesical instillation of Mitomycin-c.
- Follow up: cystoscopy at three and nine months, then yearly for five years and to be discharged if no recurrence.
2. Intermediate risk (solitary G1/2 low grade with tumour size more than 3cm, or multifocal G1/2 low-grade Ta low-risk tumour recurrence within 12 months)
- Treatment: TURBT + single dose MMC ( of a course of at least six weeks intravesical MMC ).
- Follow up: cystoscopy at 3, 6 and 12 months, then yearly for five years and to be discharged if no recurrence.
3. High risk (G3 tumour, G2/G1 T1, CIS or aggressive variants)
- Treatment: TURBT +/- single dose MMC if felt appropriate, second look TURBT within six weeks, also offer intravesical full course BCG or radical cystectomy and urinary diversion.
- Follow up: cystoscopy every three months for two years then every six months for another two to three years and then annually for life.
NB: For BCG failure the best option is radical cystectomy and urinary diversion.
Muscle invasive bladder cancer:
After doing a bone scan and staging CT for chest abdomen and pelvis with the discussion in MDT meeting, the patient should be assessed for fitness. The treatment options are either radical cystectomy and urinary diversion or radical radiotherapy.
Metastatic bladder cancer:
Treatment is debulking TURBT + cisplatin-based chemotherapy (if the patient had good performance status and adequate renal function).
What are the survival rates for bladder cancer?
The five-year recurrence-free rates:
- Ta: 85%-90%
- T1: 76%
- T2: 74%
- T3: 52%
- T4: 36%
The overall survival post radical cystectomy is 66% after five years and 43% after 10 years, but with node-positive cystectomy, the five-year survival is 34%-43%.
Mr Alanbuki would like to acknowledge his colleague Mr Michael Sidarous, a clinical fellow in urology, for his contribution to this article.
Mr Alanbuki specialises in treating bladder, prostate and kidney cancer. You can book an appointment to see him via his Top Doctor’s profile here, should you require his expert opinion in your case.