Bladder Cancer

Symptoms

Blood in your urine is the most common symptom of bladder cancer.

The medical name for blood in your urine is haematuria and it's usually painless. You may notice streaks of blood in your urine or the blood may turn your urine brown. The blood isn't always noticeable and it may come and go.

Less common symptoms of bladder cancer include:

• a need to urinate on a more frequent basis
• sudden urges to urinate
• a burning sensation when passing urine

If bladder cancer reaches an advanced stage and has spread, symptoms can include:

• pelvic pain
• bone pain
• unintentional weight loss

• swelling of the legs
  

Causes

Bladder cancer is caused by changes to the cells of the bladder. It's often linked with exposure to certain chemicals, but the cause isn't always known.

Risk Factors

Several factors have been identified that can significantly increase your risk of developing bladder cancer.

Smoking

Smoking is the single biggest risk factor for bladder cancer. This is because tobacco contains cancer-causing (carcinogenic) chemicals.

If you smoke for many years, these chemicals pass into your bloodstream and are filtered by the kidneys into your urine. The bladder is repeatedly exposed to these harmful chemicals, as it acts as a store for urine. This can cause changes to the cells of the bladder lining, which may lead to bladder cancer.

It's estimated that more than a third of all cases of bladder cancer are caused by smoking. People who smoke may be up to 4 times more likely to develop bladder cancer than non-smokers.

Exposure to chemicals

Exposure to certain industrial chemicals is the second biggest risk factor. Previous studies have estimated that this may account for around 25% of cases.

Chemicals known to increase the risk of bladder cancer include:

• aniline dyes
• 2-Naphthylamine
• 4-Aminobiphenyl
• xenylamine
• benzidine
• o-toluidine

Occupations linked to an increased risk of bladder cancer are manufacturing jobs involving:

• dyes
• textiles
• rubbers
• paints
• plastics
• leather tanning

Some non-manufacturing jobs have also been linked to an increased risk of bladder cancer. These include taxi or bus drivers, as a result of their regular exposure to the chemicals present in diesel fumes.

The link between bladder cancer and these types of occupations was discovered in the 1950s and 1960s. Today, strict regulations limit exposure to cancer-causing chemicals.

However, these chemicals are still linked with cases of bladder cancer now, as it can take up to 30 years after initial exposure to the chemicals before the condition starts to develop.

Other risk factors

Other factors that can increase your risk of bladder cancer include:

• radiotherapy to treat previous cancers near the bladder, such as bowel cancer
• previous treatment with certain chemotherapy medications, such as cyclophosphamide and cisplatin
• having certain treatments for type 2 diabetes
• having a tube in your bladder (an indwelling catheter) for a long time, because you have nerve damage that has resulted in paralysis
• long-term or repeated urinary tract infections (UTIs)
• long-term bladder stones
• an untreated infection called schistosomiasis (bilharzia), which is caused by a parasite that lives in fresh water

How bladder cancer spreads

Bladder cancer usually begins in the cells of the bladder lining. In some cases, it may spread into surrounding bladder muscle. If the cancer penetrates this muscle, it can spread to other parts of the body, usually through the lymphatic system.

If bladder cancer spreads to other parts of the body, such as other organs, it's known as metastatic bladder cancer.

Diagnosis

If you have symptoms of bladder cancer, such as blood in your urine, you should see a GP. Your GP may ask about your symptoms, family history and whether you've been exposed to any possible causes of bladder cancer, such as smoking.

In some cases, your GP may request a urine sample, so it can be tested in a laboratory for traces of blood, bacteria or abnormal cells.

Your GP may also carry out a physical examination of your rectum and vagina, as bladder cancer sometimes causes a noticeable lump that presses against them.

If your doctor suspects bladder cancer, you'll be referred to a hospital for further tests.

Tests and procedures

Some hospitals have specialist clinics for people with blood in their urine (haematuria), while others have specialist urology departments for people with urinary tract problems.

Cystoscopy

If you're referred to a hospital specialist and they think you might have bladder cancer, you should first be offered a cystoscopy.

A specialist will examine the inside of your bladder by passing a thin tube with a camera and light at the end (cystoscope) through your urethra (the tube through which you urinate).

Before having a cystoscopy, a local anaesthetic gel is applied to your urethra so you don't feel any pain. The gel also helps the cystoscope to pass into the urethra more easily.

The procedure usually takes about 5 minutes.

Imaging scans

You may be offered a CT (computed tomography) scan or an MRI (Magnetic resonance imaging) scan if the specialist feels they need a more detailed picture of your bladder. 

An intravenous (IV) urogram may also be used to look at your whole urinary system before or after treatment for bladder cancer.

During this procedure, dye is injected into your bloodstream and X-rays are used to study it as it passes through your urinary system.

Transurethral resection of a bladder tumour (TURBT)

If abnormalities are found in your bladder during a cystoscopy, you should be offered an operation known as TURBT. This is so any abnormal areas of tissue can be removed and tested for cancer (a biopsy).

TURBT is carried out under general anaesthesia.

Sometimes, a sample of the muscle wall of your bladder is also taken to check whether the cancer has spread. This may be a separate operation within 6 weeks of the first biopsy.

You should also be offered a dose of chemotherapy after the operation. This may help to prevent the bladder cancer returning, if the removed cells are found to be cancerous.

Staging and grading

Once these tests have been completed, it should be possible to tell you the grade of the cancer and what stage it is.

Staging is a measurement of how far the cancer has spread. Lower-stage cancers are smaller and have a better chance of successful treatment.

Grading is a measurement of how likely a cancer is to spread. The grade of a cancer is usually described using a number system ranging from G1 to G3. High-grade cancers are more likely to spread than low-grade cancers. 

The most widely used staging system for bladder cancer is known as the TNM system, where:

• T stands for how far into the bladder the tumour has grown
• N stands for whether the cancer has spread into nearby lymph nodes
• M stands for whether the cancer has spread into another part of the body (metastasis), such as the lungs

T stages

The T staging system is as follows:

• TIS or CIS (carcinoma in situ) – a very early high-grade cancer confined to the innermost layer of the bladder lining
• Ta – the cancer is just in the innermost layer of the bladder lining
• T1 – the cancerous cells have started to grow into the connective tissue beyond the bladder lining

Bladder cancer up to the T1 stage is usually called early bladder cancer or non-muscle-invasive bladder cancer.

If the tumour grows larger than this, it's usually called muscle-invasive bladder cancer and is categorised as:

• T2 – the cancer has grown through the connective tissue, into the bladder muscle
• T3 – the cancer has grown through the layer of muscles, into the surrounding layer of fat

If the tumour grows larger than the T3 stage, it's considered to be advanced bladder cancer and is categorised as:

• T4 – the cancer has spread outside the bladder, into surrounding organs

N stages

The N staging system is as follows:

• N0 – there are no cancerous cells in any of your lymph nodes
• N1 – there are cancerous cells in just one of your lymph nodes in your pelvis
• N2 – there are cancerous cells in two or more lymph nodes in your pelvis
• N3 – there are cancerous cells in one or more of your lymph nodes (known as common iliac nodes) deep in your pelvis

M stages

There are only two options in the M system:

• M0 – where the cancer hasn't spread to another part of the body

• M1 – where the cancer has spread to another part of the body, such as the bones, lungs or liver
  

Treatment Options

The treatment options for bladder cancer largely depend on how advanced the cancer is.

Treatments usually differ between early stage, non-muscle-invasive bladder cancer and more advanced muscle-invasive bladder cancer.

When To See A Doctor

If you have blood in your urine – even if it comes and goes – you should visit your GP, so the cause can be investigated.

Having blood in your urine doesn't mean you definitely have bladder cancer. There are other, more common, causes including:

• a urinary tract infections (UTIs), such as cystitis
• a kidney infection
• kidney stones
• non-gonococcal urethritis

• an enlarged prostate gland, in men