Geoffrey Sklar, MD answers frequently asked questions about bladder cancer.
Dr. Sklar is chair of urology at UM BWMC and clinical associate professor of surgery at the University of Maryland School of Medicine.
What are the risk factors for bladder cancer?
Bladder cancer is one of the more common cancers -- particularly among men. The bladder is in the lower part of the abdomen, and it is a common cancer. Bladder cancer is associated mainly with the aging process as well as cigarette smoking.
The most common risk factor in the United States is smoking. More than 50 percent of men and women with bladder cancer will be cigarette smokers. Even though most people think of lung cancer with cigarette smoking, and the tobacco industry puts warnings of lung cancer, bladder cancer is a very high risk. Not only is your risk higher, but your risk of recurrence and progression is higher if you continue to smoke. One of the real jobs of physicians is to get physicians--even if they've been diagnosed and treated for bladder cancer--to stop coming as the risk of recurrence and progression goes up if they continue to smoke cigarettes.
Other risk factors include exposure to work environment toxins, seen in rubber factories, as well as the textile industry, particularly dyes. But it is much more common as people age -- men have it more often than women because of smoking. But the older people get the more likely they are of getting bladder cancer. It's one of those cancers that often does not have a symptom until you see blood coming out when you urinate. That's the most common symptom people see.
What are the signs and symptoms of bladder cancer?
Blood in the urine, what we call hematuria, is the most common presenting sign or symptom of bladder cancer. Usually, blood in the urine is painless--it doesn't hurt when you urinate, you just see red in the urine. There are other signs and symptoms, the most common is frequent urination, burning with urination, or urgent urination, here the tumor irritates the lining of the bladder causing it to either bleed or make you feel like you have to urinate much more frequently.
The other symptoms we see tend to be from spread or progression of bladder cancer. It can block the kidney tubes and give you pain in your side, or it can spread to you liver, lungs or bone, giving you symptoms like coughing or back pain. The most common symptom, though, is blood in the urine, and this will be intermittent. The mistake people make is that it may occur once, it may go away, and they don't ever see a doctor or report it until it's a little bit too late.
How is bladder cancer treated?
The treatments for bladder cancer depend on the stage of bladder cancer. Briefly, I break it down into two different stages. The first is what we call "superficial bladder cancer"--a small growth in the lining of the bladder that hasn't grown into the muscle layer of the bladder. Usually this is treated--first we have to diagnose the problem, so we usually look into the bladder with a cystoscope, and we find out if there are bladder tumors. If there are bladder tumors, we either biopsy them or scrape them using a transurethral recession, done with a telescope through the urethra. We scrape the tumor to get staging--how deep it's gone into the muscle. It's also curative for those people who have superficial cancer. That one procedure, if it is confined, will be the treatment.
Many patients, when they present, will have more than one tumor or a poorly differentiated tumor. Some of those will require some treatments like therapies in the bladder, similar to chemotherapy, but not really chemotherapy--it's called immunotherapy. We place a small catheter in the bladder and still fluid into the bladder that causes inflammatory changes. The body's response to that is to attack the lining of the bladder and wipe out all residual cancer cells. We usually do that once a week for about six weeks, and it is dependent on what type of cancer patients have. It doesn't make people sick, like traditional chemotherapy. It may make them have worsening urinary frequency, or some burning with urination.
The other type of bladder tumors that grow into the muscle wall behave much more like what people consider a real cancer. These are aggressive tumors, they can spread to other areas of the body, and they cause rapid progression into the muscle or blocking the ureter tubes or spreading. Most times, we recommend as the gold therapy for treatment of bladder cancer is to take the bladder out. Sometimes patients can receive a combination of chemotherapy and radiation therapy in an attempt to preserve the bladder. This has a slightly higher incidence of recurrence, and it if does fail, we recommend taking the bladder out in addition. When you take the bladder out, you have to find a new way for urine to get to the outside of the body. We can either do that by making a small conduit that comes to the skin as a stoma, or we can create what's called a neobladder out of portions of the bowel, and hook it up to the urethra, so you can void almost normally.
What happens during surgery?
If patients undergo a cystectomy, meaning they take out the prostate, in a man, we also take out the bladder, and in a woman, sometimes we take out the uterus and a small portion of the vagina. These operations take about 4-5 hours, and the recovery is about 7 days in a hospital, depending on the type of urinary reconstruction we do, whether it's an ilial loop where it comes to the skin, or a neobladder where we take a large piece of bowel and create a new bladder, and sew it back to the urethra. The recovery is about 7 days in the hospital and 4-6 weeks as an outpatient until you're completely back to normal.
Interestingly, we are starting to do robotic cystectomy, using the da Vinci Robot (which is sually associated with prostate cancer and prostatectomy). We're starting to do cystectomy with it as well, which shortens the recovery period from surgery, shortens the time getting back to work and feeling normal.