Question 1

What is Bladder Cancer?

Accepted Answer

The bladder is a hollow organ located in the lower abdomen, within the pelvis. The bladder’s main function is to store urine that it receives from the kidney. In order to carry out this function, it has elastic, muscular walls that stretch to hold urine and expel it from the body.

Bladder cancer refers to the abnormal and uncontrollable growth of cancer cells in the bladder. According to the Singapore Urological Association, bladder cancer in Singapore is the 7th most common cancer, and it is more common in men. While bladder cancer can occur at any age, the median age of diagnosis is 69 in men and 71 in women. If the patient presents at an early stage, bladder cancer treatment can be commenced promptly, resulting in a good prognosis.

Question 2

What are the symptoms of Bladder Cancer?

Accepted Answer

Symptoms of bladder cancer can often mimic that of a urinary tract infection (UTI) or bladder stone. Some of the bladder cancer symptoms are as follows:

Blood in the urine (haematuria)
Pain in the lower abdomen/pelvic area
Pain on passing urine (dysuria), burning sensation on passing urine
Unexplained and unintentional loss of weight/loss of appetite

Question 3

When to visit a doctor

Accepted Answer

You should visit a doctor if you have any of the bladder cancer symptoms mentioned above, as they may suggest a pathology within your urinary tract. Haematuria could present as an important bladder cancer symptom, and it must be investigated even if it is in small quantities and is not always visible.

Question 4

What are the stages of Bladder Cancer?

Accepted Answer

There are five stages of bladder cancer – Stages 0 to 4. Staging is essential to denote where the cancer is, the extent of it, and how far it has spread (metastasis).

Stage 0 – This bladder cancer refers to the stage in which the cancer cells have not invaded the bladder wall and are only found in the tissue lining of the bladder. This stage is divided into two classifications known as Stage 0a (non-invasive papillary carcinoma) and Ois (carcinoma in situ) – this staging depends on the type of bladder cancer.
Stage 1 – This cancer indicates that the cancer has invaded the connective tissue but not the bladder muscle layers.
Stage 2 – This bladder cancer is a form of muscle-invasive bladder cancer which has spread into the muscle layers of the bladder.
Stage 3 – This cancer refers to bladder cancer that may have spread to surrounding structures, including the layer of fat that is around the bladder. This stage can be further classified into Stages 3A and 3B.
Stage 4 – This bladder cancer denotes metastatic cancer, which means it has spread to other organs beyond the kidney, such as the lungs, liver, bowel, and bone. This stage can also be further categorised into Stages 4A and 4B.

Once bladder cancer is diagnosed, the doctors will then proceed to stage the tumour. Staging of cancers is important because it helps to ascertain how deep the cancer has invaded the bladder or how far the cancer has spread within the body. This will determine the bladder cancer treatment plan as well as the prognosis of the patient.

Bladder cancer can be divided into two types depending on the depth of cancer invasion.

Non-muscle-invasive bladder cancer – This refers to cancer that is limited to the mucosal and submucosal layers and not invading into the bladder muscle layer.
Muscle-invasive bladder cancer – This refers to cancer that has progressed into the bladder muscles or beyond, including the bladder’s fatty layers or even to organs adjacent to the bladder.

Question 5

What are the types of Bladder Cancer?

Accepted Answer

There are several subtypes of bladder cancers, but the three main ones are as follows:

Urothelial carcinoma of the bladder
This is also known as transitional cell carcinoma and is the most common type of bladder cancer (>90%). This cancer starts from the inner lining (urothelium) of the bladder. As the urothelium lines the inner surface of the urinary tract (kidneys and ureters), urothelial carcinoma of the bladder is associated with urothelial carcinoma of the kidney or ureter.

Squamous cell carcinoma
This refers to a type of thin flat cells that line the inside of the bladder. They typically develop as a result of chronic bladder inflammation or irritation, which can arise from long-term indwelling urinary catheters, bladder stones or certain parasitic infections.

Adenocarcinoma
Adenocarcinoma is a very rare type of bladder cancer in Singapore and elsewhere, accounting for 1-2% of all bladder cancers. Adenocarcinoma of the bladder can be classified into two types – primary and secondary adenocarcinoma. Primary adenocarcinoma (arising from the bladder) is typically found at the dome of the bladder and is associated with the urachal remnant (the route where the bladder descends from the umbilicus area to the pelvis during foetal development). Secondary adenocarcinomas, on the other hand, are more common than primary adenocarcinomas and usually occur due to metastasis from a distant organ or as a result of pelvic malignancy e.g., colon cancer.

Sarcoma, micropapillary, plasmacytoid, and small cell carcinoma of the bladder are some of the other less prevalent varieties of bladder cancer. These bladder cancers are uncommon and only affect a small percentage of the population.

Question 6

How is Bladder Cancer caused?

Accepted Answer

There is no specific cause of bladder cancer, but some risk factors include:

Smoking — Several studies show that smoking is a significant risk factor for developing bladder cancer. People who smoke cigarettes have a two to four-fold increased risk of bladder cancer.
Exposure to chemicals — Years of occupational exposure to various chemicals and industrial compounds such as paints, petroleum, and dyes can increase the risk of developing bladder cancer.
Genetics —  A family history of bladder cancer can increase your risk of developing bladder cancer.
Exposure to ionising radiation – While more studies are yet to be carried out to gain a deep understanding of the link between ionising radiation and urological cancers, frequent exposure may increase the risk of bladder cancer as the bladder is sensitive to radiation.
Chronic bladder infection — Chronic and recurrent bladder infections, parasitic infections or bladder stones may lead to bladder cancer.

Question 7

Is there a link between holding in urine and Bladder Cancer?

Accepted Answer

No. While holding in your urine does not cause bladder cancer, it can put you at risk of developing urinary tract infections and other issues. Cancer, in itself, results from an overly active and excessive cellular reproduction pathway that is caused by genetic mutations of the cells in the body.

Question 8

How is Bladder Cancer diagnosed?

Accepted Answer

Your urologist will take a detailed medical history and perform a physical examination to look for any masses in your abdomen. Certain diagnostic tests may also be performed, such as:

Urine tests to check for blood and cancer cells in the urine.
Ultrasound/CT scans to obtain detailed images of the urinary tract and to check for the presence of tumours or the spread of cancer to other parts of the body.
Cystoscopy and bladder biopsy, i.e., the insertion of a thin, flexible tube with a video camera attached at the end of it through the opening of the urethra. Cystoscopy is useful as it has a lens and light system that can enable doctors to see real-time images of the bladder and identify any areas which are suspicious of cancers. Biopsies can be performed on suspicious areas to confirm the diagnosis of bladder cancer.

Question 9

Is there a blood test to diagnose Bladder Cancer?

Accepted Answer

No, there is no blood test to diagnose bladder cancer. But a renal panel (kidney function tests) may be taken at the clinic to assess your kidney function. The renal panel consists of a number of tests that assess the levels of various substances in the blood, including glucose, proteins, electrolytes and minerals. It is important to carry out this investigation as bladder cancer can cause upstream damage to the kidneys if the flow of urine is obstructed.

Question 10

How is Bladder Cancer treated?

Accepted Answer

There are a number of bladder cancer treatment modalities, and the choice of treatment option(s) depends on many factors, including the type, stage, and grade of cancer. Your overall health and medical conditions will also determine whether you are fit for surgery/chemotherapy.

Transurethral Resection of Bladder Tumours (TURBT)
TURBT is a type of surgery that removes tumours in the bladder and is generally performed under general anaesthesia. It is considered both diagnostic and therapeutic as it is done to diagnose, stage, and treat early-stage bladder cancer.

A rigid endoscopic instrument called a resectoscope will be inserted through the urethra and into the bladder (transurethral). The scope provides visualisation of the bladder, and the surgeon uses an electrocautery loop to remove the tumours from the bladder and to stop bleeding. Following removal, the excised tumours are sent for cancer confirmation as well as to assess the depth and grade of invasion.

Intravesical Immunotherapy and Chemotherapy
Intravesical chemotherapy and immunotherapy are treatments delivered directly into the bladder for the management of superficial bladder cancer. This is done through the insertion of a catheter through the urethra and into the bladder. This is generally done after TURBT when all visible bladder tumours have been resected. The main aim of this therapy is to reduce the recurrence and/or progression of bladder cancer.

Partial Cystectomy
Partial cystectomy is a surgical option that aims to preserve the bladder. If the cancer has invaded the muscle layer of the bladder wall but is localised to one area, the portion can be removed while preserving the rest of the bladder. Once this has been achieved, the hole in the bladder wall is then closed with stitches. However, partial cystectomy is only indicated in adenocarcinoma of the bladder or colon cancer invading the bladder or cancer in a bladder diverticulum. Partial cystectomy is not suitable for the vast majority of urothelial carcinomas of the bladder.

Radical Cystectomy and Urinary Diversion
Radical cystectomy involves the removal of the entire bladder and some surrounding structures, such as the prostate and seminal vesicles in men, and the uterus, fallopian tubes, ovaries, and part of the vagina in women. This is usually done in very advanced bladder cancers that have invaded the muscle and the structures beyond it.

As the entire bladder is excised, a urinary diversion is then performed to create a new pathway for urine to exit the body. This is done using a portion of the small intestine in either an ileal conduit (a urinary diversion to create a stoma from the small intestine) or a neobladder (reconstructing the bladder using part of the individual’s own small intestine).

Radical Pelvic Lymph Node Dissection (PLND)
A radical pelvic lymph node dissection is a surgery that involves the removal of lymph nodes around the pelvis, from which the bladder drains into. This surgery is usually done in conjunction with a radical cystectomy for advanced cancers that have spread to the lymph nodes.

Uro-Oncology - Bladder Cancer