Bladder Cancer

Question 1

What is the most common cause of bladder cancer in the UK?

Answer 1

In the UK, transitional cell carcinoma is by far the most common cause (around 90%). Advancing age and smoking are significant risk factors for its development.

Question 2

Are men or women more affected by bladder cancer?

Answer 2

More men than women are affected, though this appears largely due to exposure to relevant risk factors.

Question 3

What does bladder cancer typically present with?

Answer 3

It classically presents with painless haematuria. Management depends on staging and can involve trans-urethral resection of bladder tumour (TURBT), immunotherapy, chemotherapy, radiotherapy and cystectomy.

Question 4

There are approximately … cases of bladder cancer in the UK each year.

Answer 4

There are approximately 10,300 cases of bladder cancer in the UK each year.

Question 5

In 2017, bladder cancer was the …th most common cancer in the UK, accounting for 3% of new cancers. It is responsible for around 5,500 deaths.

Answer 5

In 2017, bladder cancer was the 11th most common cancer in the UK, accounting for 3% of new cancers. It is responsible for around 5,500 deaths.

Question 6

It occurs more frequently in White people when compared to those of Black or Asian heritage. The most common age group affected is those between 85-89. - what is this?

Answer 6

Bladder cancer - It occurs more frequently in White people when compared to those of Black or Asian heritage. The most common age group affected is those between 85-89.

Question 7

… … carcinoma is the most common cause of bladder cancer in the UK.

Answer 7

Transitional cell carcinoma is the most common cause of bladder cancer in the UK.

Question 8

Transitional cell carcinoma - what are they responsible for mainly?

Answer 8

Transitional cell carcinomas (TCC), also named urothelial carcinoma, arise from the transitional (urothelial) epithelium. This is a specialised epithelium that lines the urinary tract from the collecting ducts of the kidneys down to the proximal urethra. In the Western world, TCCs are responsible for around 90% of cases of bladder cancer.

Question 9

There are a number of risk factors associated with Transitional cell carcinoma, these are… (5)

Answer 9

Smoking (most important risk factor!)
Age
Occupation and chemical associated exposures (e.g. arylamines, polycyclic aromatic hydrocarbons)
Medications (e.g. cyclophosphamide)
Radiotherapy

Question 10

Schistosoma haematobium causes an infection called schistosomiasis (or bilharzia) after the person comes into contact with … …. It can cause an acute illness with chronic disease developing in some individuals. In the urinary system it can cause haemorrhagic cystitis and eventual malignancy.

Answer 10

Schistosoma haematobium causes an infection called schistosomiasis (or bilharzia) after the person comes into contact with contaminated water. It can cause an acute illness with chronic disease developing in some individuals. In the urinary system it can cause haemorrhagic cystitis and eventual malignancy.

Question 11

What are risk factors for bladder squamous cell carcinomas (SCC)?

Answer 11

Schistosoma haematobium causes an infection called schistosomiasis (or bilharzia), others include chronic cystitis/UTIs and radiotherapy.

Question 12

Rare causes of bladder cancer

Answer 12

The other causes of bladder cancer are all relatively rare. Adenocarcinomas account for around 2-3% of cases. Non-epithelial bladder cancers (e.g. sarcoma) are all very rare.

Question 13

The classical presentation of … … is macroscopic (visible) haematuria.

Answer 13

The classical presentation of bladder cancer is macroscopic (visible) haematuria.

Question 14

Clinical features of bladder cancer (4)

Answer 14

Haematuria (micro or macroscopic)
Dysuria
Urgency
Urinary frequency

Question 15

Advanced disease (bladder cancer) symptoms

Answer 15

Patients may also develop symptoms of advanced disease. These include pelvic pain, flank pain, bone pain, peripheral oedema, anorexia and weight loss.

Question 16

Suspected bladder cancer - what to do

Answer 16

All patients with suspected bladder cancer should be referred via an urgent (two-week wait) cancer pathway

NICE guidance NG12, Suspected cancer: recognition and referral advise urgent referral on the suspected cancer pathway if:

Age 45 or over and have unexplained visible haematuria without urinary tract infection.
Age 45 or over and have visible haematuria that persists or recurs after successful treatment of urinary tract infection.
Aged 60 and over and have unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test.

Additionally they advise referral in those aged over 60 with recurrent or persistent unexplained urinary tract infection.

Question 17

What investigation is done in suspected bladder cancer?

Answer 17

Cystoscopy is the diagnostic modality of choice.

Question 18

Blood tests for suspected bladder cancer

Answer 18

FBC
UE
LFT

Question 19

Urinary investigations for suspected bladder cancer:

Answer 19

Urine dip & MSU

Urinary cytology

Question 20

What diagnostic test is done for suspected bladder cancer?

Answer 20

The diagnostic standard, cystoscopy allows visualisation of the bladder and for biopsies to be taken. It can be diagnostic and therapeutic allowing TURBT to be completed.

Question 21

What imaging may be done in suspected bladder cancer?

Answer 21

Imaging

USS
CT
MRI
Imaging may be important to evaluate for other causes of presentation (e.g. renal carcinoma) or where advanced disease is suspected. In particular, CT or MRI should be considered prior to TURBT if muscle-invasive disease is suspected.

CT or MRI may be used for staging in patients with muscle-invasive, or high-risk non-muscle-invasive bladder cancer. PET-CT may also form part of the staging work-up.

Question 22

Bladder cancers are staged using what classification system?

Answer 22

Bladder cancers are staged using the TNM classification system.

Question 23

The… classification is used for bladder cancer.

Answer 23

The tumour, node and metastasis (TNM) classification is used for bladder cancer. It assigns a score for each of the primary tumour, nodal spread (if any) and distant metastasis.

Question 24

Bladder cancer is frequently divided into non-…-invasive bladder cancer and ….-invasive bladder cancer as this is key to management.

Answer 24

Bladder cancer is frequently divided into non-muscle-invasive bladder cancer and muscle-invasive (i.e. the cancer has invaded the detrusor muscle) bladder cancer as this is key to management (see below). The terms superficial and deep bladder cancer are no longer used.

Question 25

Management options are generally categorised based on the presence or absence of … invasion in bladder cancer

Answer 25

Management options are generally categorised based on the presence or absence of muscle invasion in bladder cancer

Question 26

Management of bladder cancer: Trans-urethral resection of bladder tumour (TURBT)

Answer 26

this can be completed during cystoscopy with the tumour (or suspected tumour) resected from the bladder. Detrusor muscle should be obtained with TURBT, if not, repeat must be considered. It gives a histological diagnosis allowing depth of invasion to be gauged and is used as the primary treatment of non-muscle invasive bladder cancer.

Question 27

Management of bladder cancer: Intravesical Bacillus Calmette-Guérin (BCG)

Answer 27

intravesical means within the bladder, BCG is a live attenuated vaccine used in the treatment of TB. It is used as an immunotherapy in the treatment of bladder cancer where it is thought to stimulate the immune system to attack cancer cells.

Question 28

Management of bladder cancer: Intravesical mitomycin C:

Answer 28

Intravesical mitomycin C: mitomycin is an antibiotic that has anti-neoplastic effects. It is given following TURBT to reduce the risk of recurrence.

Question 29

Management of bladder cancer: Radical cystectomy:

Answer 29

involves the removal of the entire bladder, used in muscle-invasive bladder cancer. It requires urinary diversion, this is typically achieved by removing a segment of the ileum which is used as a conduit. The ureters are plugged into the ileal conduit and an end of ileum is brought to the abdominal surface as a urostomy (i.e. urostomy and ileal conduit).

Question 30

Management of bladder cancer: Radical radiotherapy

Answer 30

involves irradiating the bladder in an attempt to cure the cancer, used in muscle-invasive disease. A radiosensitiser (e.g. mitomycin in combination with fluorouracil) is given alongside the radiotherapy.

Question 31

Management of bladder cancer: Chemotherapy

Answer 31

may be given neoadjuvant (given before primary treatment) or adjuvant therapy (given after primary treatment) in conjunction with radical cystectomy or radiotherapy. It can also be used as primary therapy in those with locally advanced/metastatic disease. Regimens are often cisplatin-based (other agents may be used in conjunction with it), cisplatin is a platinum-based chemotherapeutic that interferes with normal DNA synthesis.

Question 32

Non-muscle-invasive bladder cancer management:

Answer 32

TURBT forms the cornerstone of management in non-muscle-invasive cases. This allows for both histological diagnosis and treatment. A single dose of intravesical mitomycin C is offered in suspected cancer during the first TURBT.

Question 33

Non-muscle-invasive bladder cancer - moderate/high-risk

Answer 33

Patients at moderate risk (based on the stage and grade) are offered a course of intravesical mitomycin C. Patients with high-risk disease will typically have a repeat TURBT within 6 weeks. They can be offered intravesical BCG or radical cystectomy. This decision will be taken by the patient in conjunction with their urologist and nurse specialist taking multiple factors into account.

Question 34

Muscle-invasive bladder cancer management:

Answer 34

Management is complex and dependent on numerous factors. Specialist urology MDTs should review each case to guide management. In suitable patients, neoadjuvant cisplatin chemotherapy can be offered prior to radical cystectomy or radical radiotherapy.

The choice of radical cystectomy or radical radiotherapy (with a radiosensitiser) should be discussed (involving oncologist, urologist and nurse specialists) with the patient. All patients will need follow-up tailored to their disease and management.

Question 35

Locally advanced/metastatic bladder cancer management:

Answer 35

Generally, cisplatin-based chemotherapy is offered to suitable patients. Input from palliative care specialists is indicated in most cases. Many patients with advanced disease have troublesome symptoms, as such attention must also be paid to symptomatic control. This includes:

Intractable bleeding, Ureteric obstruction, Pelvic pain, bladder symptoms

Question 36

Many patients with advanced bladder cancer have troublesome symptoms, as such attention must also be paid to symptomatic control. This includes: (4)

Answer 36

Intractable bleeding: persistent haematuria can be troublesome and require blood transfusions. Treatment options include radiotherapy and embolisation (an interventional radiology procedure where selected feeder vessels are blocked with coils).

Ureteric obstruction: obstruction of the ureters prevents urine from draining into the bladder. This results in renal failure (due to elevated pressure being transmitted to the kidneys) and elevates the risk of serious urinary tract infections (due to stagnant urine). Treatment options include a percutaneous nephrostomy (a tube is placed in the back through the skin into a renal calyx allowing draining of urine via this tube) or a retrograde stent (stent inserted during a cystoscopy).

Pelvic pain: troublesome pelvic pain is common and normal analgesia may not be sufficient. Options include radiotherapy, chemotherapy and nerve blocks.

Bladder symptoms: includes urinary frequency, urgency, nocturia and dysuria that can impact quality of life. Radiotherapy may be given to help reduce these symptoms in those with incurable disease.

Question 37

Prognosis of bladder cancer

Answer 37

Prognosis is strongly linked to the stage of disease at the time of diagnosis.

74.1% survive one year or more after their diagnosis
52.6% survive five years or more after their diagnosis
Younger patients have longer survival, almost 75% survive five years or more if aged 15-49 at diagnosis. This is compared to around 40% in those aged 80 or older.

Question 38

Bladder cancer prognosis - one year vs five year ?

Answer 38

74. 1% survive one year or more after their diagnosis

52. 6% survive five years or more after their diagnosis