Bladder Cancer Medical Information

If you have been diagnosed with bladder cancer, or if you are concerned that you may develop cancer from taking the diabetes drug Actos, you probably have many questions about the disease. Here you will learn what bladder cancer is, its signs and symptoms, how it is diagnosed, and common treatment options for bladder cancer. As with any health condition, the more you know about bladder cancer the better you are able to work with your health care providers to make good choices and improve your chances for a positive outcome.

Medical information sources:
U.S. National Library of Medicine
American Cancer Society

What is bladder cancer?

Bladder cancer is a type of cancer that originates in the bladder, the organ of the body that holds urine before the body excretes it. According to the American Cancer Society, close to 70,000 cases of bladder cancer will be diagnosed in 2011. Bladder cancer occurs mainly in people over the age of 55 and is three times more common in men than women. Patients with type 2 diabetes who have taken Actos, Actoplus Met, Actoplus Met RX, Duetact, or Glustin for over a year may be at an increased risk of developing bladder cancer.

Bladder cancer usually occurs in the bladder wall. The wall of the bladder has several layers, including an inner layer called the “urothelium.” This is where most bladder cancers start. Rarely, bladder cancer starts in the organ’s muscle cells. Unless detected and treated early, as bladder cancer grows it penetrates the outer layers of the bladder wall.

Not all bladder cancer is the same, and a patient’s treatment options may vary based on factors such as the cancer’s “cell type,” which is determined by looking at tumor cells under a microscope. The main cell types of bladder cancer include transitional cell or urothelial carcinoma; squamous cell carcinoma; adenocarcinoma; and small cell
carcinoma. Transitional cell carcinomas comprise approximately 95% of all bladder cancers. Cancer starting in bladder muscle is called sarcoma.

Bladder cancer symptoms

Bladder cancer can cause several symptoms, although these symptoms by themselves do not necessarily mean that you have the disease. If you experience any of these symptoms be sure to tell your doctor right away, especially if you have taken the drug Actos, Actoplus Met, Actoplus Met RX, Duetact, or Glustin to control type 2 diabetes.
–Blood in the urine: Blood in the urine is often the first symptom of bladder cancer, although it is more commonly a sign of other conditions. Blood in the urine often causes the urine to be a pale yellow-red or darker red.

–Abdominal pain
–Painful or “burning” urination
–Having to urinate more than usual
–Feeling the urge to urinate when you don’t have to
–Inability to urinate
–Incontinence (urine leakage)
–Lower back pain
–Unexplained weight loss

Bladder cancer diagnosis

If your doctor suspects that you have bladder cancer, he or she may refer you to a specialist known as a urologist. The following exams and procedures are commonly used to help your doctor determine whether you have bladder cancer.

Physical exam: Your health care provider will first take a complete medical history to understand your symptoms. If you take Actos or a related drug to control type 2 diabetes, make sure the doctor knows this fact. Your doctor will then conduct a physical exam, which might include an exam of the rectum and pelvis to look for signs of a tumor.

Cytoscopy: The urologist may perform a “cystoscopy,” a procedure to look inside the bladder for signs of cancer. The cystoscopy, which can be performed either in the doctor’s office or in an operating room, involves a slender instrument comprised of a tube with a light and small camera (called a cytoscope) that is inserted through the urethra opening and into the bladder. Your doctor will use a local anesthesia to numb the area in order to minimize discomfort. Your doctor might also insert a drug called “porphyrins” into your bladder, which makes cancer cells glow when a special blue light is shined on them.

Biopsy: If during the cytoscopy your urologist sees a growth or anything that appears abnormal, he or she will take a biopsy. To do so, your doctor will insert a thin instrument through the cytoscope to take a small sample of tissue. Your doctor might also “wash” your bladder with salt water to collect cells from the bladder wall. The tissue and/or washings will then be sent to a pathology lab for analysis. The lab will then issue a “pathology report” describing whether cancer was found in the cells of the tissue and if so, the cell type of the cancer. The cell type is important to help determine treatment options for the disease.

Cytology: The lab might also perform a “cytology,” in which a pathologist examines a sample of your urine under a microscope to look for cancer cells. Your doctor might additionally order a urine culture test (to look for bacteria or signs of infection) and a urine marker test. A urine marker test looks for certain substances contained in bladder cancer cells. These include tests for NMP22 and BTA markers; the Immunocyst test; and the UroVysion test. Urine marker tests are most helpful for patients with a history of bladder cancer and are used to see if the cancer has recurred.

Understanding your biopsy results: A biopsy is the best way to determine whether you have bladder cancer and also helps to determine your treatment options. The result of your biopsy’s lab analysis, which involves studying the cells under a microscope with the help of special staining techniques, is called a “pathology report.” In addition to identifying the cancer’s cell type, the pathology report can also show whether the cancer has invaded the deeper layers of the bladder wall. If the cancer is only found in the inner layer of the bladder it is considered non-invasive. But if it has spread to the deeper layers, it is considered invasive. Invasive bladder cancer is more difficult to treat and is more likely to spread further.

The pathology report will also describe your cancer as “low grade” or “high grade.” Low grade (also called “well-differentiated”) bladder cancer is usually associated with a good outcome (prognosis) and has a lesser risk of spreading. High grade cancer (also called “poorly differentiated” or “undifferentiated”) is more aggressive, more prone to spreading, and harder to treat.

Imaging tests: In addition to biopsy and cytology, your doctor may have you undergo one or more imaging tests. These tests can help your doctor determine whether the cancer has spread outside the bladder. Here is a brief description of the some of the imaging tests your doctor might order:

–Pyelogram or urogram: An intravenous pyelogram (IVP) or urogram involves a special dye injected into a vein that helps your doctor look for tumors. A series of x-ray images are then taken to observe how the kidneys excrete the dye and how it collects in your urine. If you have a dye allergy, your doctor might instead recommend a retrograde pyelogram, in which dye is injected directly into the bladder via a catheter inserted through the urethra.

–Abdominal or pelvic CT scan: This imaging test (“CT” is short for “computed tomography”) takes several x-rays and combines them to view your organs for signs of tumor. The scan involves lying on a table that slides in and out of a cylinder-shaped scanner. Prior to the procedure, you may either drink a special liquid called “oral contrast” or have dye injected into a vein. The CT scan may also be used to take a needle biopsy by helping the doctor guide the needle into the suspected tumor.

–MRI: This is another type of imaging test that uses radio waves to look at the tissues of the body. A contrast dye may be injected into a vein before the procedure. You will then be asked to lie down in a cylinder-shaped machine and remain still while the cylinder moves around you, taking images from multiple positions. An “MRI urogram” may be used specifically to view your kidneys and bladder.

–Ultrasound: Ultrasounds use sound waves to view the organs. For this procedure you will lay on a table; the technician will put some gel on your skin then rub a wand-like instrument over the area. The technician will then view the images on a screen and take screen shots for the doctor to review. Ultrasound is sometimes used to determine whether the cancer has spread to other organs or to help perform a needle biopsy of a suspected cancer spread.

Staging: “Staging” refers to how far, if at all, bladder cancer has advanced. For bladder cancer, doctors often use the “TNM” system.
“T” stands for the main tumor. Numbers and/or letters describe the cancer’s spread and in some cases, the cell type involved. The higher the number, the more advanced the cancer. For example, “T0” stands for no evidence of a primary tumor, while “T4b” stands for a tumor that has spread to the pelvis or abdomen.

The “N” category describes the spread of cancer to the lymph nodes; for example, “N0” indicates no spread while “N2” indicates spread to at least two lymph nodes in the pelvis.

The “M” category describes whether the cancer has spread, or metastasized, to distant parts of the body. “M0” indicates no distant spread, while “M1” indicates spread to other organs or distant lymph nodes. These categories are then combined to determine the patient’s overall stage of bladder cancer, which in turn can help determine the patient’s prognosis.

The numbers used in the staging system describe how far the cancer has spread, if at all. Stage 0 means that the tumors are only in the bladder lining. Stage I means that the tumors have penetrated the bladder lining but do not affect muscle tissue. Stage II means the cancer has penetrated the bladder’s muscle layer. Stage III indicates that the cancer has spread beyond the muscle layer and into tissue outside of the bladder. Stage IV means the cancer has spread to lymph nodes outside the bladder and/or to other organs (also called “metastasis”).

Bladder cancer treatment

There are a variety of treatment options available for bladder cancer, depending on the cancer’s cell type, stage, and your body’s ability to tolerate potential side effects. Your doctor will take these factors into account when recommending a course of treatment. It is always a good idea to get a second opinion before deciding on your treatment options. The American Cancer Society provides comprehensive information about common treatment combinations suggested for the various stages of bladder cancer. Here we provide a general overview of the types of therapy your doctor might recommend to you.

Surgery: Most patients with bladder cancer undergo surgery to remove tumors and prevent recurrence. Here are the types of surgery that your doctor might recommend:

–Transurethal resection: This is the most common surgery for bladder cancer caught at an early stage. The benefit of this surgery is that your surgeon does not have to cut through the abdominal wall to perform the procedure; instead, a special instrument is placed through the urethra into the bladder to remove tumor tissue. The surgeon may also use a laser to burn the area where the tumor was removed to help kill any remaining cancer cells. This surgery is minimally invasive, and most patients recover quickly.

–Cystectomy: This surgery may be recommended for more advanced cancers. A “partial cystectomy” involves removing part of the bladder’s muscle wall and nearby lymph nodes. A “radical cystectomy” involves removing the entire bladder and nearby lymph nodes, along with the prostate (for men) or ovaries, fallopian tubes, uterus, and part of the vagina (for women). Risks of complications are higher and recovery times longer for cystectomy than for transurethral resection. Patients who have their bladder removed may also undergo reconstructive surgery to provide them with a means to hold urine.

Intravescial therapy: This is a form of treatment used for non-invasive or stage I bladder cancers to kill cancer cells in the bladder lining. Intravescial therapy involves injecting a chemotherapy or immunotherapy drug directly into the bladder through a catheter. The chemotherapy drug mitomycin may be given while heating the bladder, a treatment called electromotive mitomycin therapy.

Chemotherapy: In addition to intravescial therapy, drugs to treat bladder cancer may be given by mouth or injected into a vein or muscle. These forms of chemotherapy benefit the patient by attacking cancer cells that may have traveled beyond the bladder. Sometimes chemotherapy is administered before surgery is performed in an effort to shrink the tumor and make it easier for the surgeon to remove. Sometimes chemotherapy is given in tandem with radiation therapy to enhance its effects. Oftentimes chemotherapy drugs are used in combination to improve their effectiveness. The combination of chemotherapy drugs prescribed by your oncologist will depend on your type of bladder cancer, its stage, whether the drugs are effective in treating your cancer, and your ability to tolerate them.

Chemotherapy is typically administered several times over the course of months, with time off between treatments to let your body recover. The side effects can include nausea, fatigue, bruising, hair loss, mouth sores, loss of appetite, diarrhea, and increased risk of infection. Fortunately, drugs and other therapies can help lessen or prevent some of the side effects.

Radiation: Radiation therapy is another treatment option recommended to some bladder cancer patients. It can be used to treat bladder cancer at both early and advanced stages. Sometimes it is given in combination with chemotherapy to enhance its effect. Radiation is administered much like an x-ray. It typically requires daily treatments (Monday through Friday) over several weeks’ time. Side effects may include nausea, skin irritation, painful urination, fatigue, diarrhea, bruising, and risk of infection.