• Cancer

    Bladder cancer: What you should know about diagnosis, treatment and recurrence

Bladder cancer is one of the most common cancer types in the U.S., according to the National Cancer Institute. It's also one of the most likely types of cancer to recur.

Experts are developing ways to reduce bladder cancer recurrence, and, with treatments and follow-up care tailored to each person’s cancer, outcomes are improving. Mark Tyson, II, M.D., a Mayo Clinic urologic surgeon, explains:

Blood in the urine may be the first sign of bladder cancer.

The first symptom of bladder cancer is often blood in the urine, but Dr. Tyson says it isn't always visible. "Patients will either be told that they have blood in the urine on a test done by a primary care physician or they'll see blood in their urine. And those types of situations require immediate urologic evaluation," he says.

Some types of bladder cancer come with other symptoms, says Dr. Tyson: "This isn't common, but increased frequency and urgency of urination and frequent urination at night can be symptoms with aggressive disease."

If you have any of these symptoms and your health care team suspects you have bladder cancer, they may order a test called a cystoscopy. "It's like a colonoscopy, but it's done through the urethra with a tiny camera," says Dr. Tyson. "Unlike a colonoscopy, it doesn't require sedation, and it's performed in a doctor’s office." The cystoscope has a lens that allows the health care professional to see inside your urethra and bladder and examine them for signs of disease. During a cystoscopy, your care team may collect a cell sample ( biopsy) from your bladder for testing.

If you've had blood in your urine, Dr. Tyson recommends asking your care team about an upper tract evaluation — usually a CT urogram — to rule out cancer in other parts of your urinary system, including the ureters and kidneys.

Your care team will determine the type and stage of your cancer during diagnosis.

"Most patients are diagnosed with urothelial carcinoma. There are other types of bladder cancer, but urothelial carcinoma is the most common," says Dr. Tyson. This cancer occurs in the cells that line the inside of the bladder.

Low-stage bladder cancer is confined to the inner layers of the bladder and hasn’t grown to affect the muscular bladder wall. The highest stage — stage 4 — is cancer that has spread to lymph nodes or organs in distant areas of the body.

Treatment is based on cancer type, stage and grade.

Before recommending a care plan, your care team will grade your tumor. Tumors confined to the inner layer of the bladder can be removed and classified during a procedure called a transurethral resection of bladder tumor (TURBT), which doesn’t require incisions but does require sedation. "We put a scope into the bladder and resect the tumor, and we try to get the whole tumor out at that time," says Dr. Tyson.

Your tumor is then examined in a lab, and the results inform the next steps of your treatment. Bladder cancers are either low-grade or high-grade. Low-grade bladder cancer cells grow more slowly and are less likely to invade the bladder’s muscular wall. High-grade bladder cancer cells grow aggressively and may be more likely to spread to the bladder wall and other tissues and organs.

Treatment for bladder cancer can include chemotherapy — either directly administered to your bladder or used more broadly, radiation therapy, immunotherapy or surgery. It may also involve a combination of these treatments. "There are quality of life and toxicity considerations with each of those options, and it's up to the patient to decide which treatment option is right for them," says Dr. Tyson.

Dr. Tyson says that when bladder cancer is especially aggressive, the best course of action is typically chemotherapy followed by surgery to remove all or part of the bladder. If this is the case, your health care professional will talk to you about options for reconstruction and other approaches to restore your ability to urinate.

Careful follow-up is needed to monitor for recurrence.

Some stages of bladder cancer, and those considered high-grade cancers, are more likely to recur. Stage 0 and I cancers remain in the tissue lining your bladder and have not yet penetrated the muscle wall. According to Dr. Tyson, cancers found at these stages are most survivable, but they often come back. "These diseases recur, but they don't necessarily recur in a life-threatening fashion," he says.

Recurrence can also happen in more advanced stage and high-grade bladder cancers. "There is a subset of patients — probably about 20% — with an aggressive and invasive form of the disease that requires more aggressive treatment. In those cases, recurrence can be life-threatening," says Dr. Tyson.

If you have a high-grade, non-muscle-invasive bladder cancer, Dr. Tyson says your care team can use immunotherapy to try to prevent recurrence. Bacillus Calmette-Guérin (BCG) is a weakened bacteria that can stimulate the immune system to kill any remaining cancer cells in the bladder. "The treatment is put inside the bladder through a catheter, then patients walk around for a couple of hours," says Dr. Tyson. This gives your immune system a chance to begin attacking the cancer cells before you empty your bladder.

Based on your bladder cancer type, stage and grade, your care team will provide a follow-up plan to monitor for recurrence. Experts generally recommend a cystoscopy to examine the inside of your urethra and bladder every three to six months for the first few years after treatment. The type of testing and frequency of visits may change after a few years of surveillance without cancer recurrence.

If you’ve been diagnosed with bladder cancer, Dr. Tyson encourages you to connect with other survivors for insight and guidance. "Don't hesitate to reach out to other patients. We often have patients who volunteer to provide support," he says. "Organizations like the Bladder Cancer Advocacy Network also house a repository of patient contact information that can help." Ask your care team how to connect with other bladder cancer patients.

This article originally appeared on the Mayo Clinic Comprehensive Cancer Center blog.

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