For Patients

Bladder Cancer

What is bladder cancer and how is it diagnosed?

For further information please contact Sister Lynsey Robson, Urology Nurse Specialist, contact 0191 284 3111 ext 31730

Introduction

We hope this information will answer some of your questions about bladder cancer. Your doctor may have used the term cancer, growth, tumour, wart in the bladder or papilloma. There are several types of bladder cancer and the treatment and follow-up can be very different.

The bladder is a hollow, balloon like organ lying in your pelvis, which collects urine from your kidneys via tubes called ureters and stores it until it is full enough to empty through the urethra.

Background

Each year 9,000 people develop bladder cancer in England and Wales. It is more common in men than women. Smoking and contact with some chemicals at work are believed to be important causes. If you have worked with chemicals please let your Urologist know as you may be eligible for compensation.

Symptoms of bladder cancer

The most common symptom is blood in the urine, known as haematuria. There may be no pain and the colour may vary from rusty brown to deep red, depending on the amount of blood. It may be present some days and not others. Sometimes blood clots can form.

There are other reasons why you might have haematuria, but it is important to have it checked as soon as possible.

Diagnosis of bladder cancer

If you have blood in the urine, your GP should refer you to the hospital for further investigations. There are a range of tests and investigations which you will have and these will include:

• blood and urine tests which will give the doctor an indication of your general health and how well your kidneys are working.
• An ultrasound scan of your kidneys which produces a picture using sound waves, takes under 15 minutes and is completely painless.
• X-rays of your kidneys, which may include a CT scan using contrast dye which will give additional information on the outline of your kidneys, ureters and bladder.
• an inspection of your bladder (cystoscopy) which is a telescopic examination allowing the urologist to inspect the inside of your bladder. A flexible cystoscope is used with local anaesthetic (i.e. it can be done while you are awake), so you will be able to return home shortly afterwards.

Under some circumstances it may be recommended that you have a general anaesthetic, for example if tissue samples (biopsies) need to be taken. The biopsies are then examined under a microscope to establish whether there are any cancerous cells, and if so, what kind they are.

If this is the case, Sr Lynsey Robson or one of her deputies will be available if you would like to discuss this further or would like time to ask any other questions.

What can you do to help yourself?

The most important action you can take is to report any blood in your urine to your GP as soon as possible, so that it can be investigated and appropriate treatment started.

If you have been diagnosed as having bladder cancel it is very important that you come for regular check-ups.

Cigarette smoking is one cause of bladder cancer. If you stop smoking the risk is reduced. Even if you have bladder cancer, stopping smoking will reduce the risk of developing more tumours in the future.

How invasive bladder cancer is treated

Surgery, radiotherapy and chemotherapy can be used alone or in combination to treat invasive bladder cancer. The appropriate treatment will be discussed with you, taking into account your age, general health, the type and size of the tumour, and whether it has spread. Your case will be discussed at a special meeting involving a clinical oncologist (who treats patients using radiotherapy and chemotherapy), the urologist and a pathologist (the specialist who looks at your biopsies).

Not all these cancers can be cured, but we will make certain you are offered the best treatment for your circumstances, and you will have the opportunity to discuss all your options. You may find it helpful to bring a friend or relative with you.

Surgery

Cystectomy

This operation involves total removal of the bladder (complete or radical cystectomy) and can be done with the DaVinci robot. It has been reported to have the highest cure rate. However it is a major operation and carries an increased risk of side effects compared with other options (see below). The exact cure rate will depend on the type of tumour but the average rate is 40 – 50%.

In women the operation usually involves the removal of the bladder, the urethra, the lower end of the ureters, part of the front wall of the vagina, the womb (hysterectomy), the fallopian tubes and ovaries. In younger women the ovaries will be left if possible. As a result of the operation the vagina may be shorter and narrower. Sexual feeling and climax may be affected after the operation.

In men the bladder; the prostate gland, the lower ends of the ureters and sometimes the urethra are removed. It is sometimes impossible to avoid damage to the nerves in the pelvis, with the result that men will be unable to achieve an erection, and sexual feeling and orgasm (climax) may be impossible. In some men, the inability to obtain an erection can be helped by injections or an operation (penile prosthesis).

It can be difficult or embarrassing to discuss sex with your doctors and nurses, but remember they are used to discussing personal matters. lf you have a partner it may be very helpful for them to see the specialist or one of the nurses before the operation is performed, and we are happy to include them in the discussions with your permission.

The operation of cystectomy is extensive, but its aim is to give the best chance of cure, and to reduce the chance of recurrence of the cancer as much as possible.

Replacing the Bladder

lf the bladder has been completely removed, a new reservoir for the urine will have to be created. A piece of bowel is used, which can give rise to mucous in the urine, rarely to diarrhoea, and occasionally to infections in the urine. There are various ways the new reservoir can be created.

Ileal conduit or Urostomy formation

This is the standard method. A small section of bowel is used to join the ureters from the kidneys to the skin on your abdomen. The remaining bowel is joined together again. The opening (stoma or urostomy) drains the urine into a flat, changeable watertight bag which you wear on the side of your abdomen. This will gradually fill up in the same way as your bladder did, and will need to be emptied regularly by a small tap at the bottom of the bag.

Bladder reconstruction

Increasingly often nowadays it is possible to fashion a new ‘bladder reservoir’ inside the abdomen by using a bowel segment which is shaped into a balloon and stitched it to the top of the urethra (urine pipe). It may be possible to empty the bladder normally by straining to pass urine, but you may have to learn to pass a small tube or catheter (intermittent self catheterisation or ISC) to drain the urine 3 or 4 times a day. Most patients (90%) are dry or continent during the day, but some patients (more often older patients) may have some leakage at night and so may have to wear a small pad for protection.

Continent pouch

lf the urethra has to be removed a continent pouch can be formed, again using a piece of bowel. This means that although you do not pass urine out through the urethra, you do not have to wear a bag either. Instead you will be taught how to drain the urine by passing a small catheter into the new bladder every 3 hours through your umbilicus or navel.

There are booklets available that deal with cystectomies, urostomies, reconstruction and continent pouches in more detail.

These operations are major procedures. There is a specialist nurse called the Stoma care sister who will advise and help you before and after your operation, teach you to look after your urostomy, bladder or pouch, liaise with your GP and nurses at home and see you regularly after your operation. She will also be able to introduce you to someone who has already had your operation so that you can find out how other people cope, and give you information on support groups in the area.

Radiotherapy

Radiotherapy treats the cancer with high energy X-rays, whilst doing as little harm as possible to surrounding healthy cells. It may be given before, after or instead of surgery. The cure rate is between 30 – 40%, but some patients still need to have their bladder removed.

The treatment is usually given daily, Monday to Friday at the Newcastle Cancer Centre based at Freeman Hospital. The exact amount of radiotherapy depends on the disease and your general health. The treatment usually takes 4-6 weeks. Radiotherapy planning is meticulous in order to give the tumour cells the maximum dose, and you the minimum side effects.

At each treatment the radiographer will position you carefully and line up marks on your skin with the machine. Your treatment only takes a few minutes each day and you will not feel anything. You will not need to stay in hospital overnight.

Radiotherapy can cause tiredness, tender skin, diarrhoea and an irritated bladder. The side effects should resolve within a few weeks after your treatment has finished, but let your doctor know of any side effects.

After radiotherapy you will need to continue with regular cystoscopy examinations.

Systematic Chemotherapy

This type of chemotherapy involves giving drugs which kill multiplying cells (cytotoxics) into the veins rather than directly into the bladder (intravesical chemotherapy). Chemotherapy is normally given in addition to surgery or radiotherapy.

Side effects vary, but with modem anti-sickness drugs, vomiting is not as common as it was, although you may feel sickly and lose your appetite. Your sense of taste may also change. Complete hair loss is unusual with most of the drugs we use for bladder cancer, but your hair may lose its condition and get thinner. Other side effects such as mouth ulcers, tiredness, irritability, loss of sex drive and a greater susceptibility to infection can occur, but settle after treatment.

Transurethral Resectuion of Tumour (Turbt) and Partial Cystectomy

Rarely, it may be possible to cut out the tumour and the section of bladder involved. This may be done either as a telescopic procedure (TURBT) or as a cutting operation through the abdomen (partial cystectomy). After the operation you will be able to pass urine normally.

This operation is accompanied by radiotherapy or systemic chemotherapy. After 5 years a number of patients will get recurrence which then requires cystectomy.

Overview

Invasive bladder cancer is a serious disease. Several treatments may be used (cystectomy, radiotherapy, chemotherapy). Each option may not be appropriate for each patient, and their side effects and their impact on your life vary. You will need to discuss them with your specialist, nurses, GP and family. Do not be afraid to ask questions and go over all the information with us until you are sure you understand what is happening.

How superficial bladder cancer is treated

lf you need any further information please contact Sister Lynsey Robson, Urology Nurse Specialist, on 0191 284 3111 ext 26115

There are several types of bladder cancer:

1. Superficial bladder cancer (tumours growing on the lining of the bladder)
2. Carcinoma–in–situ (CIS)
3. Muscle invasive bladder cancer
4. Metastatic or advanced bladder cancer – cancer that has spread beyond the bladder

Superficial Bladder Tumours

Most (70%) bladder cancers are superficial and look like tiny sea anemones growing on the inside lining of the bladder. They are sometimes known as papillary tumours; in the past they were sometimes called papillomas or bladder warts. There may be more than one tumour present.

Treatment of Superficial Tumours

They can be completely removed by cutting them off under anaesthetic using a cystoscope and a cautery loop. This operation is called transurethral resection of bladder tumour (TURBT). The tumours are then sent for microscopic examination. Small tumours are removed completely by this treatment but unfortunately the bladder may develop further tumours over time. It is therefore very important to have regular bladder inspections (cystoscopies) every few months to check that the bladder remains healthy and tumour free.

Your Urologist will advise you how often you will need to come to hospital for cystoscopies once he/she has looked in your bladder and seen the laboratory results from your biopsies.

Intravesical Drug Treatment

In addition to the removal of the tumour(s) and regular cystoscopies, you may be asked to attend hospital as an out-patient to have intravesical chemotherapy or immunotherapy (BCG). Studies have shown that the likelihood of developing further tumours is reduced by washing the bladder out with one of several drugs. This treatment may be given just once after your cystoscopy, or on a weekly basis for 3 or 6 weeks depending on what is most appropriate for YOUR bladder.

Out-patient treatment is given via a small tube (catheter) gently passed through the urethra into the bladder after the use of local anaesthetic. You are asked to hold the drug in your bladder for 1-2 hours (depending on the drug) before emptying your bladder in the normal way and going home. If appropriate, we can arrange for you to have this treatment in your own home.

While most people complete their treatment with no problems, it may help to know that the following side effects CAN occur and what to do if this happens.

You may need to empty your bladder more often, and it may be uncomfortable when you do. You may develop a rash on your hands, or experience sweats or shivers on the evening of your treatment. You will be given more detailed information about your particular treatment, but it is important that you drink plenty of fluids (something every hour) after treatment and contact the hospital if you have any concerns.

Follow-up

For most patients the longer term future will involve regular but less frequent cystoscopies, and occasional admissions to hospital for extra treatment.

Carcinoma in situ (CIS)

This is a particular type of bladder cancer in which the lining of the bladder appears inflamed and is covered with rather abnormal cells. This can develop into a more invasive tumour if it is left untreated.

Your Urologist may discuss several types of treatment with you. You may need to come back a little earlier (at about 6 weeks) for a repeat resection of the area of the tumour, and it is likely that you will be offered an initial 6 weeks of BCG treatment into your bladder followed by regular BCG treatment. Your Urologist may recommend removal of the bladder in some circumstances.

In conclusion, your treatment options will always be discussed with you, and the most appropriate course chosen only after you have had the opportunity to consider your options and ask any questions.