Oct 29, 2017
November is National Bladder Health Awareness Month. According to the Urology Care Foundation the cost of treating bladder problems in the United States is 70 Billion dollars annually. Nursing home costs due to urinary incontinence are estimated at 6 billion dollars annually. Urinary tract infections create more than 8 million doctor visits every year (5.3 of those 8 million visits are women with infections, 1.3 and 1.2 of those 8 million are children and men respectively). Millions of Americans have neurogenic bladder – a lack of bladder control due to a brain, spinal cord or other nerve problem such as spinal cord injury, multiple sclerosis, Parkinson’s disease, stroke, spina bifida, or nerve problems caused by diabetes or major pelvic surgery. An estimated 33 million adults in the U.S. may have overactive bladder. As if that weren’t enough, here is a humbling statistic. More than 1 in 10 military service members injured in Afghanistan and Iraq have urologic trauma injuries, damaging the urinary tract or reproductive organs. In preparation for National Bladder Health Awareness Month today we are going to talk about bladder cancer. Although it doesn’t make the newspapers much bladder cancer is the 5th most common non-skin cancer in the United States. It is the 4th most common cancer diagnosed in men and by the Veterans Affairs Health System. Nearly 600,000 Americans live with bladder cancer today and 75-80,000 people will be diagnosed in the United States with bladder cancer this year. An estimated 16-17,00 people will die from bladder cancer this year. According to the American Cancer Society bladder cancer is more common as a person grows older. 90% of patients with a new diagnosis of bladder cancer are over age 55, with the average age at diagnosis being 73 years old. Bladder cancer is three times more common in males than females. Whites are diagnosed with bladder cancer about twice as often as African or Hispanic Americans, but African-Americans present more commonly with advanced disease. You are at risk for bladder cancer if you are over 55 years of age and you have one of the following five risk factors: 1. You smoke tobacco, either in the past or currently. Smoking tobacco may be the cause of half of all bladder tumors. If you need another reason to stop smoking if you are a smoker, please add bladder cancer to your list, 2. You are at risk for bladder cancer if you are exposed to chemicals in the workplace used to make plastics, paints, textiles, leather and rubber, 3. you have had prior pelvic radiation, 4. you have chronic urinary tract infections associated with neurologic disease and chronic catheterization and less commonly 5. you are a patient taking some medications linked with increasing bladder cancer risk such as the chemotherapy cyclophosphamide, the diabetes drug Actos, or dietary supplements containing aristolochic acid (mainly in herbs from the Aristolochia family). I have recently diagnosed patients with bladder cancer without significant risk factors other than age and gender. One gentleman I saw recently had come in for a routine follow up appointment for his enlarged prostate and elevated PSA number. The day before his appointment, however, he had seen blood in his urine and mentioned it casually at the end of his appt. He was having no other symptoms. Urologists take blood in the urine very seriously. Blood in the urine is the most common symptom of bladder cancer. When bleeding occurs because of bladder cancer it is generally painless, and is seen in the entire urine stream. If you see blood in your urine you should tell a healthcare provider so they can refer you to a urologist. Even if the blood goes away, you should still talk to your doctor about it. When you see blood in the urine, it is called "gross hematuria." Often, however, you cannot see the blood in your urine but it is detected by the laboratory with a microscope during routine checks of the urine such as during an annual physical exam. A very small amount of blood might be normal in some people and not lead to a medical condition, but ALL patients require evaluation when the amount of blood detected on the urinalysis is more than just a trace amount. Blood in the urine does not always mean that you have bladder cancer either. There are a number of other more common reasons why you may have blood in your urine: urinary tract infection, enlarged prostate or prostate infection, kidney or bladder stones, kidney disease, kidney trauma, or kidney cancer, blood thinning drugs and even a tough workout (what we call runner’s hematuria) can cause blood in the urine. When blood is found in the urine, even if it’s a small amount, you need to make sure there is not a tumor in the kidney or bladder, or a kidney stone or infection. We have to evaluate the kidneys, ureters, bladder, and the urethra to try to identify a source for the bleeding. A CT scan or ultrasound is ordered to look at the kidneys and ureters, with a CT scan with and without IV contrast dye being the recommended test in most cases. We can run a urine cytology or other bladder tests on the urine to see if there are changes that would indicate bladder cancer. But to evaluate specifically for bladder cancer, unfortunately, the best test is to actually look inside the bladder with a scope. We have to perform a cystoscopy, a procedure to look inside the bladder. A cystoscope is a thin flexible instrument that has a light and camera or fiberoptics at the end of it allowing us to see directly inside the bladder. To get into the bladder we have to pass the cystoscope through the urethra. Cystoscopy is done as an outpatient procedure in the clinic. The average cystoscopy takes just a minute or two. As you would expect the procedure is uncomfortable, and carries with it a small risk of infection from the introduction of the scope into the bladder. A cystoscopy is the most common procedure done in our office. There are many reasons we perform cystoscopy, to rule out cancer of course but also to evaluate the urethra, prostate, and bladder anatomy. Other symptoms of bladder cancer as well as many other urologic problems may include changes in urination. Frequent urination or pain when you pass urine called dysuria are less common symptoms of bladder cancer and often indicate other problems such as infection or overactive bladder. But to evaluate these symptoms more completely we will often perform cystoscopy, even if cancer is not suspected. Cancer is when your body cells grow out of control when the normal DNA instructions for cell growth are disrupted. Most cancers form a lump called a tumor. In the case of bladder cancer that growth occurs inside the bladder and we can visualize it directly with the scope. A review of anatomy is appropriate. The bladder is a hollow organ in the pelvis with flexible, muscular walls. The bladder is where the body stores urine before it leaves the body. The bladder can get bigger or smaller as it fills with urine and empties. When you go to the bathroom, the muscles in your bladder will contract. They then push urine out through a tube called the urethra. In addition to the muscular layer of the bladder the bladder wall has other layers, made up of different types of cells. The inner lining is called urothelium lined by a special type of cells called transitional cells. Transitional cells are designed to make a transition are able to change shape from very bunched up and contracted when the bladder is empty to being very stretched out and thin when the bladder is full. In a word, they “transition.” Because most bladder cancers start in the urothelium or transitional epithelium, bladder cancer is often called transitional cell carcinoma. Other types of bladder cancer exist but are much less common and include squamous cell carcinoma (cancer that begins in thin, flat cells lining the bladder) and adenocarcinoma (cancer that begins in cells that make and release mucus and other fluids). Transitional cell carcinomas grow typically as a polypoid growth, with a stalk and are referred to as being papillary. A person with bladder cancer will have one or more tumors in the lining of the bladder that, if I would have to describe it, appear like mini cauliflower floret, or like a sea coral waving from the ocean floor. Bladder cancers attach to the bladder wall on the lining or the surface. That is called a non-invasive tumor. As the polyp grows it can begin to invade through the top most part, the transitional epithelium to the layers underneath. Bladder cancer gets worse when it grows into or through other layers of the bladder wall. The first layer it invades is a connective layer called the lamina propria. If the cancer begins to invade into the lamina propria layer it becomes a stage 1 cancer. If the cancer is just on the surface it is not considered a stage 1 cancer but rather is referred to as superficial or a stage A cancer. Underneath the lamina propria is a muscle layer called the detrusor muscle. When the tumor reaches the muscle layer it becomes a stage 2 cancer and has a much higher chance of spreading. Beyond the muscle is the fatty connective tissue holding the bladder in place. If the cancer reaches that level it becomes a stage 3 caner. Over time, the cancer becomes a stage 4 bladder cancer grows outside the bladder into tissues close by. Bladder cancer may spread to lymph nodes, lungs, liver, bones and other parts of the body. Stage 2, 3, and 4 cancers require more surgery, radiation, and chemotherapy. Superficial and Stage 1 tumors may need more surgery or treatments instilled into the bladder. When we look inside a bladder and see a tumor or growth we can’t officially call it a cancer until we have a biopsy. Diagnosis of bladder cancer is confirmed and staged most commonly during a transurethral resection of a bladder tumor (TURBT). For many patients, the resection of the bladder tumor will be the only treatment they need. The tumor is resected under anesthesia in the hospital or surgery center. A scope is placed in the bladder that has a working element that can cut the tumor off of the surface of the bladder. At this time, your doctor will stage your cancer and try to cut it away completely to get rid of the cancer. The surgeon will resect or remove all of the visible tumor if possible and send the biopsy to a pathologist who will review the specimen and assign it a stage and grade. What is left in the bladder can best be described as a divot, much like a golfer leaves his mark on the fairway, because the urologist has to get deep enough to cut the tumor completely out if possible. The bladder heals very fast, relining itself quickly with healthy urothelium. Grade and stage describe a cancer’s development and guide future treatment. A tumor grade tells how aggressive the cancer cells are. A tumor stage tells how much the cancer has spread. We have already reviewed the tumor stages above. The pathologist will review the specimen and also assign a grade to the cancer. Tumors can be low or high grade. High-grade tumor cells are very abnormal, poorly organized and tend to be more serious, faster growing cells that are more likely to recur after they are removed and to invade the other layers of the bladder. A low-grade tumor has cells that are abnormal, but less aggressive looking and more uniform in character. They tend to behave less aggressively in terms of putting patients at risk for recurrence or invasion to other layers of the bladder. As I said before many patients are treated with simple resection of the bladder tumor. If the bladder cancer is superficial and low grade the treatment is most often just the removal and routine follow-up cystoscopy in the office. 50% of bladder cancers will recur. Just like dandelions in the yard, the seeds for next year’s growth may lie somewhere else in the bladder already at the time of removal. Careful follow-up is critical to finding tumors early if they recur and treating them before they advance. Routine cystoscopy is initially performed usually on a 3 months basis to make sure we catch bladder cancers early, increasing that interval as appropriate. Our story today ends on a happy note. My patient with the blood in his urine fortuitously just one day prior to his routine f/u with me had superficial bladder cancer and I was able to remove it during the transurethral resection of his bladder tumor. Although he doesn’t need further treatment at this time we will need to follow him carefully because of the high rate of recurrence of tumors. Although we don’t hear much about bladder cancer, it is a very common disease. Fortunately, many patients can simply have a procedure done in the hospital without further treatment. For patients needing more treatment we will have the opportunity to talk about other options for more aggressive tumors in future episodes. Let me leave you with this thought. It’s best to just not get bladder cancer in the first place. There are risk factors that we can’t do anything about but the biggest risk factor for bladder cancer is smoking. If you are smoker quit today.