Bladder cancer

The bladder

The bladder is part of the body’s urinary system. It stores and gets rid of urine.

Bladder cancer begins when cells inside the bladder change and grow out of control.

Each year, almost 3,100 Australians find out they have bladder cancer. Most people diagnosed with bladder cancer are 60 years or older, but it can occur at any age.

About 1 in every 140 males will be diagnosed with bladder cancer before age 75, making it one of the 10 most common cancers in males.

Signs and symptoms of bladder cancer

Sometimes bladder cancer doesn’t have many symptoms. Signs or symptoms can include:

• blood in your urine
• needing to urinate often or urgently
• pain or burning when passing urine
• not being able to pass urine when you need to.

Less commonly, people may have pain in one side of their lower abdomen (belly) or back. They may also lose their appetite and lose weight.

Not everyone with these symptoms has bladder cancer. If you have any of these symptoms or are worried, always see your doctor.

Risk factors for bladder cancer

There are some things that can make you more likely to develop bladder cancer. These are called risk factors and they include:

• Smoking – people who smoke are up to 3 times more likely than non-smokers to develop bladder cancer.
• Age – about 90% of people diagnosed with bladder cancer in Australia are aged over 60.
• Being male – men are around 3 times more likely than women to develop bladder cancer.
• Chemical exposure at work – chemicals called aromatic amines, benzene products and aniline dyes are linked to bladder cancer. These chemicals are used in rubber and plastics manufacturing, in the dye industry, and sometimes in the work of painters, machinists, printers, hairdressers, firefighters and truck drivers.
• Parasitic bladder infections – one of the rarer types of bladder cancer (squamous cell carcinoma of the bladder) has been linked to a parasitic bladder infection called schistosomiasis. This is very rare in people born in Australia; it is caused by a parasite found in fresh water in Africa, Asia, South America and the Caribbean.
• Long-term catheter use – using urinary catheters over a long period may be linked with squamous cell carcinoma of the bladder
• Previous cancer treatments – some types of radiation therapy around the pelvis, and the chemotherapy drug cyclophosphamide
• Diabetes treatment – The diabetes drug pioglitazone can increase the risk of bladder cancer.
• Personal or family history – most people with bladder cancer do not have a family history. However, having one or more close blood relatives diagnosed with bladder cancer, or having inherited a gene linked to bladder cancer, slightly increases the risk of bladder cancer.

Having these risk factors doesn’t mean you will develop bladder cancer. Often there is no clear reason for getting bladder cancer. If you are worried about your risk factors, ask your doctor for advice.

Tests for bladder cancer

Your doctor may do some tests to check for bladder cancer:

• internal examination – the doctor may check inside your bottom or vagina with their finger, using gloves
• urine tests – your urine will be checked for signs of bladder cancer
• blood tests – to check your general health
• ultrasound – a scan on the outside of your abdomen to check for cancer
• CT scan and x-rays – scans that take pictures of the inside of the body, sometimes also called a CT-IVP or a triple phase abdominal-pelvic CT scan
• MRI scan – a scan that uses magnetism and radio waves to take pictures of the inside of the body
• cystoscopy – the doctor puts a small camera into your bladder to see inside
• biopsy – the doctor takes a small sample of the cells from the bladder to check for signs of cancer
• Transurethral resection of bladder tumour (TURBT) – the doctor performs a cystoscopy and removes or destroys the tumour.

Your doctor might ask you to have further tests. These can include:

• bone scan – a scan that uses dye to show changes in your bones
• PET-CT scan – a scan that uses an injection of liquid to show cancer cells.

Types of bladder cancer

Bladder cancer can be described based on where it is found:

• superficial (non-muscle invasive) – the cancer has not spread to other layers of the bladder or muscle
• muscle-invasive – the cancer has spread to other layers of the bladder, muscle or other parts of the body.

There are 3 main types of bladder cancer:

• urothelial carcinoma – 80 to 90% of bladder cancers – sometimes called transitional cell carcinoma
• squamous cell carcinoma – 1 to 2% of all bladder cancers. It is more likely to be invasive (spread)
• adenocarcinoma – about 1% of all bladder cancers. It is more likely to be invasive (spread).

There are other, less common types of bladder cancer. Treatment for these may be different. Speak to your doctor or nurse for information about these types of cancer.

Stages and grades of bladder cancer

Stages and grades of cancer describe how far it has spread and how quickly it is growing.

Stages

The stage of a cancer means how far it has grown in your body. The most common way doctors decide on a stage for bladder cancer is the TNM system (tumour, nodes metastasis). This system describes:

• how far the tumour has grown into the wall of the bladder and nearby tissues
• if the cancer has spread to nearby lymph nodes
• if the cancer has spread to other parts of the body.

Some doctors put the TNM scores together to produce an overall stage, from stage 1 (earliest stage) to stage 4 (most advanced). Ask your doctor or nurse to explain the stage of the cancer.

You can also read more from the Cancer Council about the TNM system and staging.

Grades

The grade of the cancer means how quickly a cancer might grow. Knowing the grade helps your doctors work out the best treatment plan for you:

• low grade – the cancer cells are usually slow-growing. Most bladder tumours are low grade
• high grade – the cancer cells look very abnormal and grow quickly. They are more likely to spread. Almost all muscle-invasive cancers are high grade.

Note: ‘Bladder carcinoma in situ’ is a specific type of bladder cancer. It is an early stage cancer but is always high grade. This means it can grow quickly and might spread. If you have bladder carcinoma in situ your doctor will start treatment straight away. Treatment for this type of bladder cancer can be very effective. Your treatment team can tell you more.

Prognosis and survival rates for bladder cancer

When someone is diagnosed with bladder cancer, their doctor will give them a ‘prognosis’. A prognosis is the doctor’s opinion of how likely the cancer will spread and the chances of getting better. A prognosis depends on the type and stage of cancer, as well as the person’s age and general health.

Bladder cancer can usually be effectively treated if it is found before it spreads outside the bladder.

If you have bladder cancer, your doctor will talk to you about your individual situation when working out your prognosis. Every person’s experience is different, and there is support available to you.

Treatment for bladder cancer

Treatment for bladder cancer depends on how quickly the cancer is growing. Treatment is different for non-muscle invasive bladder cancer and muscle-invasive bladder cancer.

You might feel confused or unsure about your treatment options and decisions. It’s okay to ask your treatment team to explain the information to you more than once. It’s often okay to take some time to think about your decisions.

When deciding on treatment for bladder cancer, you may want to discuss your options with a urologist, radiation oncologist and medical oncologist. Ask your GP for referrals.

Treatment for superficial bladder cancer

Treatments for superficial bladder cancer include:

• surgery
• immunotherapy
• chemotherapy.

Surgery

Most people with superficial bladder cancer have an operation to remove the cancer. The most common operation is called TURBT (transurethral resection of bladder tumour). Sometimes you might need to have a second TURBT or a different surgery.

For some people bladder cancer can come back after surgery. You will need to have regular follow-up tests. This way you can start appropriate treatment if the cancer comes back.

Chemotherapy

This treatment uses medication to destroy or slow the growth of cancer cells, while causing the least possible damage to healthy cells. Intravesical chemotherapy goes directly into the bladder through a tube called a catheter. It is only used for non-muscle-invasive bladder cancer to help keep the cancer from coming back. You may have one dose or more than one dose, depending on your situation.

Immunotherapy

Immunotherapy uses your own immune system to treat cancer. Immunotherapy for bladder cancer uses a treatment called Bacillus Calmette-Guérin (BCG) to stop or slow down the cancer. Because this immunotherapy goes directly into the bladder through a tube (catheter) it is called intravesical immunotherapy.

A combination of BCG and TURBT is most effective. BCG is given once a week for 6 weeks, starting 2–4 weeks after TURBT surgery. It is put directly into the bladder through a catheter. This may happen in a hospital or clinic. The treatment may have to be repeated depending on your response.

Treatment for muscle-invasive bladder cancer

When bladder cancer has invaded the muscle layer, the main treatment options are:

• surgery to remove the whole bladder (cystectomy), sometimes with chemotherapy given before or after the surgery
• bladder-conserving surgery (TURBT), followed by radiation therapy with or without chemotherapy (trimodal therapy).
  

Surgery (cystectomy)

Some people with muscle-invasive disease have surgery to remove the bladder (cystectomy). The surgeon usually needs to remove the whole bladder (radical cystectomy).

Systemic chemotherapy

For muscle-invasive bladder cancer, chemotherapy is injected into a vein. This is called systemic chemotherapy. You may have chemotherapy:

• before surgery, to shrink the cancer and make it easier to remove (neoadjuvant chemotherapy)
• after surgery, if there is a high risk of the cancer coming back (adjuvant chemotherapy)
• with radiation therapy (chemoradiation) and surgery as part of trimodal therapy
• to treat bladder cancer that has spread to other parts of the body.

Chemotherapy is given as a course, at regular intervals for several months.

Radiation therapy

Radiation therapy uses a controlled dose of radiation to kill or damage cancer cells. The radiation is usually in the form of x-ray beams. Radiation therapy to treat bladder cancer is used as part of trimodal therapy, either on its own or combined with chemotherapy.

Trimodal therapy

You may have trimodal therapy as the main treatment for muscle-invasive tumours.

Trimodal therapy may be used if a person is unable to have surgery to remove the bladder or would prefer to keep their bladder. It is most suited for people whose bladder is working well and smaller tumours that haven’t spread.

Trimodal therapy involves:

• a shorter surgery to remove the tumour from the bladder (TURBT), followed by
• radiation therapy combined with chemotherapy (chemoradiation). The chemotherapy makes the cancer cells more sensitive to radiation. Some people who are not fit enough for chemotherapy will have radiation therapy on its own.

Talk to your medical team about whether trimodal therapy may be an option in your situation.

Treatment for advanced bladder cancer

If bladder cancer has spread to other parts of the body, it is known as advanced or metastatic bladder cancer. You may be offered one or a combination of the following treatments to help control the cancer and ease symptoms:

• systemic chemotherapy
• immunotherapy
• surgery
• radiation therapy.

Immunotherapy uses the body’s own immune system to fight cancer. BCG is a type of immunotherapy treatment that has been used for many years to treat superficial bladder cancer.

A new group of immunotherapy drugs called checkpoint inhibitors work by helping the immune system to recognise and attack the cancer. After a course of chemotherapy, some people with advanced bladder cancer may have immunotherapy with checkpoint inhibitor drugs such as pembrolizumab or avelumab.

These drugs are given directly into a vein through a drip (infusion) and the treatment is repeated every 2–6 weeks. How many infusions you receive will depend on how you respond to the drug.

Side effects of treatment for bladder cancer

All cancer treatments can have side effects. Your treatment team will discuss these with you before you start treatment. Talk to your doctor or nurse about any side effects you are experiencing. Some side effects can be upsetting and difficult, but there is help if you need it.

Call Cancer Council (Tel. 13 11 20, or Tel. 13 14 50 for an interpreter) or contact cancer support to speak with a caring cancer nurse for support.

What to do before and after treatment

Talk with your doctors about whether you need to do anything to prepare for treatment and help your recovery. Some things they may suggest are to:

• Stop smoking – if you smoke, aim to quit before starting treatment. If you keep smoking, you may not respond as well to treatment and you may have more treatment-related side effects. Continuing to smoke also increases your risk of cancer returning.
• Begin or continue an exercise program – exercise will help build up your strength for treatment and recovery. It can also help you deal with side effects of treatment.
• Improve diet – aim to eat a balanced diet with a variety of fruit, vegetables, wholegrains and protein. Eating well can improve your strength and you may respond better to treatment.
• See a physiotherapist – they can teach you exercises to strengthen your pelvic floor muscles, which help control how your bladder and bowel work. These exercises are useful if you have a neobladder, a partial cystectomy, or radiation therapy.
• Talk to someone – you may find it useful to talk to a psychologist or counsellor about how you are feeling. This can help you deal with any anxiety about having surgery and any longer term changes after treatment.

Bladder reconstructions and stomas

If you have had your bladder removed, the way you pass urine will change. There are several options that your treatment team will talk to you about:

• Urostomy (sometimes called an ileal conduit) is where doctors create a new hole in your abdomen called a stoma. Urine drains from the stoma to the outside of your abdomen into a special bag.
• Neobladder is where a new bladder made from your small bowel forms a pouch inside your body to store urine. You will pass urine by squeezing your abdominal muscles. You will also pass a small tube (catheter) into the neobladder (pouch) each day to help drain the urine.
• Continent urinary diversion is a pouch made from your small bowel inside your body to store urine. The urine empties through a hole called a stoma to the outside of your abdomen into a special bag.

A bladder reconstruction is a big change in your life. You can speak with a continence or stomal therapy nurse for help, support and information. You can also call Cancer Council (Tel. 13 11 20). You may be able to speak with a trained Cancer Council volunteer who has had cancer for tips and support.

If you find it difficult to adjust after your bladder reconstruction, it may help to be referred to a psychologist or counsellor.

Note: If you have a stoma, you can join a stoma association for support and free supplies. For more information about stoma associations, visit the Australian Council of Stoma Associations.

Sexuality, fertility and bladder cancer

Having bladder cancer and treatment can change the way you feel about yourself, other people, relationships and sex. These changes can be very upsetting and hard to talk about. Doctors and nurses are very understanding and can give you support. You can ask for a referral to a counsellor or therapist who specialises in body image, sex and relationships.

Changes for men after a cystectomy may include damaged nerves to the penis, orgasm changes and fertility changes.

Changes for women after a cystectomy may include vaginal changes such as narrowing, shortening or dryness, changes to sexual arousal and the ability to orgasm, menopause and fertility changes.

If you may want to have children in the future, talk to your treatment team.

Living with advanced cancer

Advanced cancer usually means cancer that is unlikely to be cured. Some people can live for many months or years with advanced cancer. During this time palliative care services can help.

Most people continue to have treatment for advanced cancer as part of palliative care, as it helps manage the cancer and improve their day-to-day lives. Many people think that palliative care is for people who are dying but palliative care is for any stage of advanced cancer. There are doctors, nurses and other people who specialise in palliative care.

Treatment may include chemotherapy, radiation therapy or another type of treatment. It can help in these ways:

• slow down how fast the cancer is growing
• shrink the cancer
• help you to live more comfortably by managing symptoms, like pain.

Treatment depends on:

• where the cancer started
• how far it has spread
• your general health
• your preferences and what you want to do.

Ask your doctor about treatment and palliative care services that may help you.

Support for carers, family and friends

Caring for someone with cancer can be difficult sometimes. If you are caring for someone with bladder cancer, these organisations can help:

• Cancer Council Tel. 13 11 20
• Carer Gateway Tel. 1800 422 737
• Carers Australia Tel. 1800 514 845

Where to get help

• Your GP (doctor)
• Your treatment team
• Urologist
• Oncologist
• Cancer Council Victoria. Tel. 13 11 20
  • Information and support line Tel. 13 11 20 (or 13 14 50 for an interpreter)
  • Bladder cancer
  • Cancer Council Victoria, My Cancer Guide - Find support services that are right for you.
• WeCan website – helps people affected by cancer find the information, resources and support services they may need following a diagnosis of cancer
• Continence Foundation of Australia Tel. 1800 330 066
• NURSE-ON-CALL Tel. 1300 60 60 24