BLADDER CANCER – Causes and Risk Factors, Staging, Clinical Manifestations, Diagnostic Evaluations and Management
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BLADDER CANCER – Causes and Risk Factors, Staging, Clinical Manifestations, Diagnostic Evaluations and Management

Bladder cancer refers to any of several types of malignant growths of the urinary bladder. Bladder cancer accounts for approximately 90% of cancers of the urinary system.

The bladder is a hollow, muscular organ located in the pelvic cavity that stores and discharges urine. Urine is produced by the kidneys, carried to the bladder by the ureters, and discharged from the bladder through the urethra.

Of the different types of cells that form the bladder, the cells lining the inside of the bladder wall are most likely to develop cancer. Any of three different cell types can become cancerous. The resulting cancers are named after the cell types.

  • Urethelial carcinoma: The most common type of bladder cancer begins in cells lining the inside of the bladder and is called transitional cell carcinoma (urothelial cell carcinoma). In transitional cell carcinoma, these normal lining cells undergo changes that lead to the uncontrolled cell growth characteristic of cancer.
  • Squamous Cell Carcinoma: These cancers originate from the thin, flat cells that typically form as a result of bladder inflammation or irritation that has taken place for many months or years
  • Adenocarcinoma: These cancers form from cells that make up glands. Glands are specialized structures that produce and release fluids such as mucus
  • Urothelial carcinomas account for more than 90% of all bladder cancers. Squamous cell carcinomas account 3 to 8%  and adenocarcinomas account 1 to 2%​


CAUSES AND RISK FACTORS

Cancer causing agents (carcinogens) in the urine may lead to the development of bladder cancer. The following factors increase a person’s risk of developing a bladder cancer:

A. Smoking: Cigarette smoking contributes to more than 50% of cases, and smoking cigars or pipes also increases the risk. Smokers have more than twice the risk of developing bladder cancer as nonsmokers
B. Chemical exposures at work: People who regularly work with certain chemicals or in certain industries have a greater risk of bladder cancer than the general population. Organic chemicals called aromatic amines are particularly linked with bladder cancer. These chemicals are used in the dye industry. Other industries linked to bladder cancer includes rubber and leather processing, textiles, hair coloring, paints and printing.
C. Diet: People whose diet include large amounts of fried meats and animal fats thought to be at higher risk of bladder cancer

 

OTHER RISK FACTORS INCLUDE THE FOLLOWING:

  • Age: Seniors are at the highest risk of developing bladder cancer
  • Sex: Men are three times more likely than women to have bladder cancer
  • Race: Whites have a much higher risk of developing bladder cancer
  • Personal history of bladder cancer
  • Family history of bladder cancer
  • Chronic bladder inflammation
  • Birth defects
  • External beam radiation
  • Consumption of Aristolochia fangchi (herb used in some weight loss formulas)
  • Treatment with certain drugs (e.g. cyclophosfamide)


 

STAGING OF BLADDER CANCER


The following stages are used to classify the location, size and spread of the cancer, according to the TNM staging system:

Stage 0: Cancer cells are found only on the inner lining of the bladder

Stage I: Cancer cells have proliferated to the layer beyond the inner lining of the urinary bladder but not to the muscles of the urinary bladder

Stage II: Cancer cells have proliferated to the muscles in the bladder wall but not to the fatty tissue that surrounds the urinary bladder

Stage III: Cancer cells have proliferated to the fatty tissue surrounded the urinary bladder and to the prostate gland, vagina, or uterus, but not to the lymph nodes or other organs.

Stage IV: Cancer cells have proliferated to the lymph nodes, pelvic or abdominal wall, and/or other organs

Recurrent: Cancer has recurred in the urinary bladder or in another nearby organ after having been treated

 

CLINICAL MANIFESTATIONS

Bladder cancer characteristically causes blood in the urine; this may be visible to the naked eye (gross hematuria) or detectable only by microscope (microscopic hematuria). Other possible symptoms include pain during urination, frequent urination (polyuria) or feeling the need to urinate without results. These signs and symptoms are not specific to bladder cancer, and are also caused by non-cancerous conditions, including prostate infections and cystitis. Kidney cancer also can cause hematuria.

 

DIAGNOSTIC EVALUATIONS

Diagnosis of bladder cancer includes urological tests and imaging tests. A complete medical history is used to identify potential risk factors.

  • Screening tests: Screening tests are usually performed periodically, for example, once a year or once every five years. The most widely used screening tests are medical interview, physical examination, urinalysis, urine cytology, and cystoscopy.
  • Urinalysis: This test is actually a collection of tests for abnormalities in the urine such as blood, protein and sugar. NMP22BladderChek is a urine test used to detect elevated levels of a nuclear matrix protein (called NMP22). Bladder cancer increases levels of this protein in the urine, even during early stages of the disease.
  • Urine cytology: In this test, a sample of the urine is examined under a microscope to look for abnormal cells that might suggest cancer.
  • Cystoscopy: A very narrow tube with a light and a camera on the end (cystoscope) is used to examine the inside of the bladder to look for abnormalities such as tumors. The cystoscope is inserted into the bladder through the urethra
  • Biopsy: Tiny samples of bladder wall are removed, usually during cystoscopy. Small tumors are sometimes completely removed during the biopsy process
  • Imaging tests: Various imaging tests may also be performed. Intravenous pyelogram (IVP) is the standard imaging test for bladder cancer. In this procedure, a contrast agent (radiopaque dye) is administered through a vein and x-rays are taken as the dye moves through the urinary tract. IVP provides information about the structure and function of the kidneys, ureters and bladder. Other imaging tests include CT scan, MRI scan, bone scan and ultrasound.​


 

MANAGEMENT

Treatment for bladder cancer depends on the stage of the disease, the type of cancer, and patient’s age and overall health. Standard therapies for bladder cancer include surgery, radiation therapy, chemotherapy, and immunotherapy or biological therapy.

1. Surgery: Surgery is by far the most widely used treatment for bladder cancer. It is used for all types and stages of bladder cancer. Several different types of surgery are used.

Transurethral resection with fulguration: in this operation, an instrument (resectoscope) is inserted through the tumor by cutting it or burning it with electrical current (fulguration). This is usually performed for the initial diagnosis of bladder cancer and for the treatment of stage I and II cancers. Often, after transurethral resection, intravesical therapy is given to help treat the bladder cancer.

Radical cystectomy: In this operation, the entire bladder is removed, as well as its surrounding lymph nodes and other structures that may contain cancer. This is usually performed for cancers that have at least invaded into the muscular layer of the bladder wall or for more superficial cancers.

Segmental or partial cystectomy: In this operation, part of the bladder is removed. This is usually performed for solitary low-grade tumors that have invaded the bladder wall but are limited to a small area of the bladder.

In men, the standard surgical procedure is a cystoprostatectomy (removal of the bladder and prostate) with pelvic lymphadenectomy. The seminal vesicles also may be removed. In women, the standard surgical procedure is radical cystectomy with pelvic lymphadenectomy. Radical cystectomy in women also involves removal of the uterus, ovaries, fallopian tubes, anterior vaginal wall, and urethra.

 

2. Chemotherapy: Chemotherapy drugs are administered orally, intravenously, or in early bladder cancer, may be infused into the bladder through the urethra (intravesical chemotherapy). Chemotherapy can be administered before surgery (neoadjuvant therapy) or after surgery (adjuvant therapy). Drugs commonly used to treat bladder cancer include thiotepa, mitomycin and doxorubicin.

 

3. Radiation therapy: Radiation may be given for small muscle-invasive bladder cancers. External beam radiation is emitted from a machine outside the body and internal radiation is given by placing a small pellet of radioactive material inside the bladder. Radiation therapy is also used to relieve symptoms (palliative treatment) of advanced bladder

 

 

4. Immunotherapy: Immunotherapy, also called biological therapy, may be used in some cases of superficial bladder cancer. A vaccine derived from the bacteria that causes tuberculosis (BCG) is infused through the urethra into the bladder, once a week for 6 weeks to stimulate the immune system to destroy cancer cells. Sometimes BCG is used with interferon.

 

5. Photodynamic Therapy: Photodynamic therapy is a new treatment for early bladder cancer. It involves administering drugs to make cancer cells more sensitive to light and then the light is aimed at the tumor and destroys tumor cells.

 

NURSING MANAGEMENT

  1. Assist the patient to minimize irritation voiding symptoms by fluid management and avoidance of bladder irritants.
  2. Administer urinary analgesics or antispasmodic medications as ordered to manage intense bladder irritation induced by intravesical chemotherapy
  3. Advise the patient of dosage, administration, scheduling and side effects of intravesical chemotherapy. Assess the patient for myelosuppression before each treatment
  4. Provide frequent, small meals to minimize nausea related to chemotherapy. Assist the patient with oral hygiene before meals to maximize the appetite.
  5. Monitor vital signs for hypertension or compromised renal function. Administer antihypertensive medications as ordered.
  6. Monitor hematocrit, hemoglobin and complete blood count for anemia with renal cell carcinoma or blood loss from tumor.
  7. Administer analgesic drugs as indicated for cancer-related pain to provide comfort.
  8. Assist the patient in positional changes to relieve local or generalized discomfort from bone metastasis.


 

BLADDER CANCER – Causes and Risk Factors, Staging, Clinical Manifestations, Diagnostic Evaluations and Management