Bladder Cancer: What Patients Need to Know

Each year, nearly 75,000 people are diagnosed with bladder cancer. While more common in men over age 55, bladder cancer can—and does—affect women and men of all ages.

If you or a loved one has been diagnosed with bladder cancer, you may have a lot of questions. We talked to UNC Health bladder cancer specialists Shekinah Elmore, MD, Matthew I. Milowsky, MD, Michael Repka, MD, and Angela B. Smith, MD, to learn what newly diagnosed patients and their loved ones should know about bladder cancer.

The Bladder

Located in your pelvis, the bladder stores urine before it leaves your body. Your bladder is a hollow organ that is lined by layers of muscle tissue that stretch to hold urine, which is made in the kidneys.

Bladder cancer usually begins in the lining or inner layer of your bladder wall. If left untreated, your cancer can grow through those muscular layers of the bladder wall. It can become harder to treat when this happens.

Risk Factors for Bladder Cancer

Bladder cancer generally affects older men, and smoking is a major risk factor. Occupational exposures, such as working in a factory with carcinogens, increase risk too.

To understand why smoking and chemical exposures can lead to bladder cancer, it helps to think about how things actually get out of your body—a lot of them, including the toxins and carcinogens in tobacco smoke—go through your urine.

“Sometimes before you urinate, carcinogens are just sitting there in the bladder and the interior surface of the bladder is exposed to them,” Dr. Repka says.

Researchers at the UNC School of Medicine have also found a connection between vaping and bladder cancer for similar reasons—the carcinogens and toxins associated with vaping are filtered through urine and then sit in the bladder, creating the same effect they would have in the lungs, Dr. Smith says.

Women who get bladder cancer are less likely to be smokers, and their bladder cancer is usually detected at a later stage when it is more advanced.

“We don’t know exactly why this is and researchers at UNC are investigating whether inflammation of the lining of the bladder, which occurs more often in women, could be an explanation—but we just don’t know yet,” Dr. Smith says.

Signs and Symptoms of Bladder Cancer

If caught early, bladder cancer is very treatable and often cured. The most common bladder cancer symptom is blood in the urine, which can be either visible or microscopic.

The blood in your urine can be intermittent—meaning it can occur once and then not occur again for years.

“Don’t ignore it. It may be years before you see it again, and by then, your cancer could have spread,” Dr. Smith says. “Unless a doctor has determined you have a urinary tract infection through lab work, as soon as blood is found in your urine, you need further evaluation and testing.”

Testing includes a cystoscopy, which is when a urologist places a small camera through your urethra into your bladder. It also includes imaging of your kidney and ureter (the kidney tube that drains urine into the bladder). This is typically done with a special kind of CT scan called a CT urogram.

“The reason we do both of those diagnostic studies is because the CT scan is looking for blood that is coming from the kidney and the ureter, and the cystoscope is looking for blood coming from the bladder or the urethra,” Dr. Smith says. “Blood can come from any part of the urinary system, so those two studies allow us to more comprehensively evaluate the entire urinary system.”

How Bladder Cancer Is Diagnosed

If these tests indicate you have bladder cancer, the next step is to determine what kind of bladder cancer you have and what kind of treatment is needed.

This is done through a procedure called transurethral resection of bladder tumor (TURBT). While you are under anesthesia, your urologist will place a rigid cystoscope through the urethra without making an incision. This cystoscope—known as a resectoscope—is different than the cystoscope used for diagnosis.

“A resectoscope allows us to remove the tumor from the bladder wall,” Dr. Smith says. “Imagine the bladder is like a balloon, and a tumor might be growing on the inner wall of that balloon. We use the resectoscope to very carefully shave the tumor from the wall without perforating, or putting a hole in, the bladder.”

Once this is done, the tumor is sent to a pathologist who determines the stage and the grade of the cancer. This information is needed to decide the best treatment options.

“The grade is very important for bladder cancer. It tells you the potential of what the cancer might do. It looks at whether the cancer’s features are aggressive—meaning it could spread—or not aggressive—meaning that it’s not likely to spread,” Dr. Smith says. “Then the stage looks at what layer of the bladder wall that the low- or high-grade tumor is invading.”

In other words, the stage tells you where the cancer is in your body, how far it has spread and how advanced it might be.

“A low-grade tumor isn’t going to invade the muscle wall, whereas a high-grade tumor could be noninvasive or invasive into the muscle wall. Either way, a high-grade tumor has the potential to become invasive, and that determines how we treat the cancer,” Dr. Smith says.

Treatment Options for Bladder Cancer

There are different types of treatment options because there are different types of bladder cancer, Dr. Smith says.

If the cancer is low-grade and noninvasive, sometimes all it requires is the TURBT for diagnosis and then surveillance. “This is where we continue to watch and look in the bladder regularly to make sure the tumor doesn’t return,” Dr. Smith says.

If the tumor is high-grade and noninvasive, the urologist will first make sure that the TURBT has removed all the tumor. Then the patient will receive intravesical therapy via a liquid that is placed into the bladder once a week for six weeks to help treat the cancer and prevent it from recurring.

A Team Approach to Treatment of Advanced Stage Bladder Cancer

If the tumor is invasive and high-grade, meaning it goes into the muscle of the bladder or beyond, then treatment is much more aggressive and can include chemotherapy and radiation, as well as a cystectomy, where the bladder and some reproductive organs are removed.

At UNC Health, the exact treatment plan for these patients is determined by a team of bladder cancer specialists that includes urologists, radiation oncologists and medical oncologists.

“Patients with bladder cancer that is invading the muscular layer of the bladder wall will see medical oncology for the chemotherapy piece, but they’re seen at the same time—at their initial visit—by urology and radiation oncology because sometimes we can use a combination of chemotherapy and radiation to try to spare the bladder and not remove it,” Dr. Milowsky says.

For example, some patients with muscle-invasive bladder cancer receive trimodality therapy (TMT).

“This is a combined multidisciplinary approach, where the urologist goes in and takes out as much of that visible tumor as possible, and often, leaves the bladder quite clean of any tumor,” Dr. Elmore says. “Then, a few weeks later, after some healing time, we’re able to use early focused, targeted radiation to the bladder, along with some systemic (chemo) therapy. This allows people to keep their bladder, which is nice.”

Other treatment options include new immune therapies and antibody-drug conjugates, which are like “smart bombs” that target particular proteins in the cancer.

“Another option is targeted therapies, which target specific molecular alterations within the tumor,” Dr. Milowsky says.

Patients whose cancer has spread beyond the bladder to other parts of the body, such as the lungs, liver or the bone, are also seen at the multidisciplinary clinic.

“We don’t typically operate in those settings because it’s not in a single organ any longer and some kind of systemic therapy such as chemotherapy and/or radiation is needed,” Dr. Milowsky says.

Bladder Cancer Survival Rates

Early detection and treatment increase your chances of living longer with bladder cancer. In fact, the five-year survival rate for early-stage bladder cancer is 96 percent.

If you have blood in your urine or are concerned about being at high risk for bladder cancer, talk to your primary care provider or contact the UNC Health Bladder Cancer Center of Excellence.