Bladder cancer often starts in the lining of the bladder. A person with bladder cancer has one or more tumors made up of abnormal and unhealthy cells.

There are two main categories of bladder cancer:

• Non-muscle invasive bladder cancer (NMIBC) is cancer that grows only in the thin tissue on the inside surface of the bladder. With NMIBC, the bladder muscle is not involved. The tumor is not likely to spread outside the bladder. About 70% of bladder cancers are NMIBC.
• Muscle invasive bladder cancer (MIBC) is cancer that spreads into the thick muscle deep in the bladder wall.

Another category of bladder cancer includes:

• Advanced metastatic bladder cancer which happens over time as the tumor may grow outside the bladder into tissues close by. The cancer may then spread to lymph nodes, the lungs, the liver and other parts of the body.

Bladder cancer can also be described based on stage, from stage 1 to 4. Earlier stages are easier to cure. Knowing the stage of a cancer helps your doctor decide the best way to treat it.

“However, non-muscle invasive bladder cancer, or stage 1 disease, is best described by risk group: low, intermediate or high risk,” Dr. Porten said. “These groups more accurately reflect the chance of the cancer’s recurrence and progression.”

Smoking is the most important risk factor for bladder cancer. The best way to prevent bladder cancer is to quit smoking, or never start. Other risk factors include:

• A family history of bladder cancer
• Age and gender
  • Men in the age group 75-84 are at a higher risk
• The cancer drug cyclophosphamide
• Radiation to the pelvis
• Workplace exposure
  • Chemicals used to make plastics, paints, leather and rubber.
  • Vietnam veterans who were exposed to Agent Orange may be at increased risk of bladder cancer.
  • Firefighters may have an increased risk from inhaling a number of combustible products in fires.

Not everyone with bladder cancer has symptoms. The most common sign of bladder cancer is blood in the urine. If you see blood in your urine, tell your doctor right away.

Blood in the urine does not always mean you have bladder cancer. There are many other possible causes, like a urinary tract infection. It is important to be evaluated by your doctor to find out the cause.

Other signs of bladder cancer can include:

• Frequent and urgent need to pass urine
• Pain when you pass urine
• Pain in your lower abdomen
• Back pain

If you are diagnosed with bladder cancer, your doctor will recommend treatment based on many factors. These include the stage of your cancer (the depth of the tumor and how far it has spread), your general health and your age. “Ask about side effects of treatment and what the treatment will involve,” Dr. Porten said. “Your doctor will help you choose a treatment that will get you the best balance of quantity and quality of life.”

If you have NMIBC, the doctor will do a surgical procedure called transurethral resection of the bladder tumor (TURBT). With a TURBT, the surgeon uses a cystoscope, which passes through your urethra (the tube that brings urine from the bladder to the outside of the body). The cystoscope has a light at the end so your doctor can look into your bladder and see well enough to take tumor samples and remove the tumor.

Many patients are treated with TURBT in combination with intravesical therapy to lower the risk the cancer will return. With this treatment, the doctor puts medicine in a liquid form directly into the bladder, through a catheter. The drug works on the cells that line the bladder, without having major effects on other parts of the body. This avoids the types of side effects, such as hair loss, often caused by other types of chemotherapy.

There are two types of intravesical therapy: immunotherapy and chemotherapy.

• Intravesical immunotherapy is a treatment that boosts the ability of your immune system to fight the cancer. Bacillus Calmette-Guerin (BCG) is an immunotherapy drug used for bladder cancer. You may get this treatment more than once. Some patients need many courses. The first course will likely last for about six weeks. The treatment is usually done in your doctor’s office. After the bladder is free of disease, your doctor may suggest more treatment with the same drugs to keep the tumor from coming back.
• Intravesical chemotherapy can be given right after surgery, or after recovery from TURBT. The chemotherapy drugs are placed directly into the bladder to reduce the risk of your cancer returning or slow cancer growth. They help stop cancer cells from going to another place in the body and growing. Some people need more than one course.

If you have MIBC, there are two common treatment options. The most common treatment option is bladder removal, with or without chemotherapy. The second common treatment option is chemotherapy with radiation.

Removing the entire bladder is called radical cystectomy. In men, the doctor will remove the bladder, nearby lymph nodes, part of the urethra and the prostate. In women, the surgeon may remove the uterus and ovaries along with the bladder. “Aside from typical side effects associated with major surgery, both men and women can have sexual side effects and impaired fertility,” Dr. Porten said. It is of great value to note that not all patients are able to have bladder removal surgery. Radiation may help treat those patients who are not eligible for full bladder removal.

For MIBC, chemotherapy is usually given before a radical cystectomy. Removing the bladder plus chemotherapy raises the survival rate for bladder cancer patients. Most of the time, chemotherapy will be offered before bladder removal. Not all patients are able to have chemotherapy and some patients may choose not to have chemotherapy before surgery. You may still need to have it after surgery based on the tumor stage. It is likely that bladder surgery will take place about six to eight weeks after you have finished treatment. If you did not have chemotherapy before surgery, you may receive chemotherapy or immunotherapy after.

When your bladder is removed or partly removed, your urine will be stored and made to leave your body by a different route (called urinary diversion).

There are several types of urinary diversion:

• Ileal conduit or urostomy: To make an ileal conduit, the surgeon will take a piece of your upper intestine to make a passageway for urine. It is attached to the surface of your abdomen through an opening called a stoma. The ureters (tubes that carry urine from the kidneys to the bladder) are joined to this so the urine leaves your body by the opening. A small bag is attached to the outside of your abdomen to collect the urine. You can empty the bag throughout the day.
• Continent cutaneous reservoir: Your surgeon makes a pouch inside your body. You will learn to use a catheter to remove your urine through a channel that is accessed from the surface of your abdomen.
• Orthotopic neobladder: Your surgeon makes an internal pouch to store urine. Your ureters are joined to this new “bladder.” You are able to empty through your urethra similar to before surgery. Some people may need to use a catheter to remove the urine.

“Bladder cancer is often a treatable disease,” Dr. Porten said. “It’s important to learn as much about your diagnosis as you can, and understand your options. Ask for help from your family and friends as you work with your doctor to make decisions about the treatment that will be best for you.”

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