5 Things Patients Should Know about Bladder Cancer

By: David Grew MD MPH

Five things all patients and family members dealing with a new diagnosis of badder cancer should know.

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When I meet patients with a new diagnosis of bladder cancer, usually there is a look on their face of information fatigue.  Not only are they processing an emotionally charged and potentially life threatening diagnosis, they’re also getting served volumes of complex (but very important!) information about treatment options.  I put together a list of 5 things all patients and family members dealing with a new diagnosis of badder cancer should know.  This is based on actual questions from my own patients.  Here we go:

Prevalence: How common is bladder cancer?  First of all, bladder cancer can happen in both men and women, although it is more common in men.  It is more common than you might think, ranking in the top ten cancers in the US.  There are over 80,000 new cases and 16,000 deaths annually in the US from bladder cancer.  Even as an oncologist, these numbers were surprising to me.  

Risk Factors:  Smoking tobacco is one of the strongest risk factors for bladder cancer.  Why would this happen?  Perhaps because even though you inhale smoke into your lungs, chemicals in the smoke get absorbed into your blood.  Some of these chemicals are carcinogens - which is a medical word that means they can cause cancer.  Once in the blood, they get filtered out through the kidneys and excreted in the urine.  Urine sits in the bladder - like a reservoir - before you go to the bathroom to urinate.  If the urine is loaded with carcinogens, it is bathing the inner lining of the bladder cancer causing chemicals all day.  Over time - months, years, decades - this insult can lead to mutations or changes in bladder cells that touch the urine.  As these mutations accumulate, eventually a cancer forms.  There are other chemicals that can cause bladder cancer just like tobacco.  The most common chemicals are used in the rubber, textile or dye industries. Some patients with bladder cancer have worked industrial jobs where they were routinely exposed to these chemicals, possibly leading to cancer.

Older age is also a risk factor for bladder cancer.  It is very unusual for young people to get bladder cancer.  The average age at the time of a new diagnosis is 73, and about 50% of cases occur between the ages 65 and 80.  Gender is also a risk factor, since bladder cancer is more common in men than women.  Repeated (also known as chronic) bladder infections can increase the risk of bladder cancer.  There is a slightly higher risk of bladder cancer in people who have a strong family history of bladder cancer.

Diagnosis:  The most common symptoms in patients with bladder cancer are blood in the urine, frequent urination, difficulty urinating or pain while urinating.  Sometimes patients have pain or a sensation of fullness in the pelvis or the flank region.  The very first thing doctors typically do is take a thorough history and physical exam - trying to tease out some of the risk factors listed above as well as the pattern and onset of symptoms. The next step usually includes tests of both the blood and urine.  Doctors are looking for things that may indicate an underlying cancer - like abnormal cells in the urine, blood in the urine or low blood counts.  In advanced cases, bladder cancer can affect blood work that measures kidney function.  Next, your doctor might recommend a cystoscopy, which is a procedure in which a small camera is inserted into the bladder through the urethra.  Doctors look for problems inside the bladder and if they find anything concerning, they typically take a biopsy, or remove a small piece of tissue.  The biopsy is examined under a microscope and doctors can see if there is any cancer.  A biopsy of the tumor is the only way to establish a diagnosis of bladder cancer.  You can’t make a diagnosis with a scan or a physical exam.

Staging:  In short, staging answers the question “how advanced is my bladder cancer?” The first key piece of information here is to understand how deep into the bladder the cancer invades.  Usually doctors get information about the depth of invasion from the cystoscopy and biopsy.  Some cancers are very superficial and don’t invade at all - they are called “in-situ”.  Some invade into the next layer below the surface, called the lamina propria (T1 tumors).  Some go deeper still, past the lamina propria into the muscle of the bladder wall (T2).  Less common but possible, some tumors burrow completely through the wall of the bladder into the tissue around the outside of the bladder (T3).  When bladder cancer invades into other adjacent organs like prostate, seminal vesicles, uterus, vagina, pelvic or abdominal wall - it is called T4.  Other key information for staging includes whether or not it has spread to lymph nodes or other organs elsewhere in the body.  Typically doctors order imaging studies with CT scan with IV contrast which will light up the urinary system to get more detailed information about the bladder cancer location.  In some cases they may order an MRI or a PET/CT, especially in more advanced or higher stage cancers.  These tests can give finer detail about the size, location and whether or not the cancer has spread to other organs.

Treatment:  The optimal bladder cancer treatment depends on a combination of information.  I split this information into 2 categories - tumor factors, and patient factors.  Tumor factors include all the specific features of the cancer itself - size, grade, stage, location, whether or not it responds to the first treatment, how deep it invades into the bladder.  Patient factors include age, overall health, ability to tolerate treatments like chemotherapy or surgery, whether or not there are other serious medical problems like heart or lung disease or kidney failure.  

For the earliest stages of disease (before the cancer has grown through the mucosa into the bladder muscle), doctors try to avoid surgery and instead infuse cancer treatments directly into the bladder.  This is called “intravesical therapy.”  For patients who don’t respond to this treatment, and for those with more advanced disease at the time of diagnosis, surgery is usually the next option.  Surgery is called a cystectomy and requires removal of the entire bladder.  To improve quality of life, sometimes surgeons can construct a new bladder after the cancerous bladder is removed. For patients who want to avoid surgery, non-invasive treatment with radiation combined with chemotherapy can be curative, even for advanced disease.  For patients who choose surgery, chemotherapy may be given first, to try to shrink the tumor as much as possible before it is surgically removed.  The type of chemotherapy used depends on kidney function.  Common chemotherapies include cisplatin and gemcitabine.  Immunotherapy is now being used for bladder cancer as well.  Immunotherapy is a drug that is infused by IV and activates the patients own immune system to battle the cancer.

Bonus: For patients looking for access to the latest drug and medical device technology, who also want to volunteer and potentially improve the lives of future cancer patients, clinical trials may be a good option.  You can view our educational videos about clinical trial participation here.  We created an educational video for the IMMORTAL clinical trial for patients with metastatic bladder cancer, which you can see here.

AS ALWAYS, THIS IS NOT MEDICAL ADVICE.  THIS IS FOR EDUCATIONAL PURPOSES ONLY.  TALK TO YOUR DOCTOR BEFORE MAKING ANY MEDICAL DECISIONS.

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FAQs:

How does the prevalence of bladder cancer compare between men and women, and what factors contribute to its higher incidence in men?
One significant factor is the higher prevalence of smoking among men, which is a major risk factor for bladder cancer. Smoking exposes individuals to carcinogens, which are absorbed into the bloodstream and excreted in urine, potentially causing mutations in bladder cells over time. Additionally, occupational exposure to certain chemicals in industries such as rubber, textile, or dye manufacturing can contribute to bladder cancer risk, and historically, men have been overrepresented in these occupations. Furthermore, biological differences between men and women may also play a role in the variation of bladder cancer incidence.

What are the typical side effects associated with different treatment options for bladder cancer?

Common treatments include intravesical therapy, surgery (cystectomy), radiation therapy, chemotherapy, and immunotherapy. Each treatment option has its own set of potential side effects. For example, intravesical therapy may cause urinary tract irritation or discomfort, while cystectomy can result in changes in urinary function and potential complications related to the surgical procedure itself. Chemotherapy and radiation therapy may lead to side effects such as fatigue, nausea, and skin irritation. Immunotherapy, while generally well-tolerated, can cause immune-related adverse events such as rash, diarrhea, or inflammation of organs.

How do patient-specific factors influence treatment decisions and outcomes for bladder cancer, especially when considering options like surgery, chemotherapy, or participation in clinical trials?

Older patients or those with significant comorbidities may be less tolerant of aggressive treatments like surgery or chemotherapy and may opt for less invasive approaches or participation in clinical trials. Conversely, younger, healthier patients may be better candidates for more aggressive interventions aimed at maximizing the chances of cure or disease control. Participation in clinical trials can offer access to innovative treatments and technologies, but patient eligibility and willingness to undergo experimental therapies are also important considerations in treatment decision-making.