Bladder cancer

Notes

Overview

Bladder cancer is a common malignancy, in 2017 it was the 11th most common cancer in the UK.

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

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

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

Epidemiology

There are approximately 10,200 cases of bladder cancer in the UK each year.

In 2017, bladder cancer was the 11th most common cancer in the UK, accounting for 3% of new cancers. It was responsible for around 5,400 deaths in 2017.

In affects more men than women, in 2017 it was the 8th most common cancer in men (7,400 cases) and the 16th most common in women (2,800 cases).

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.

Fortunately over the past decade rates have been falling and are projected to keep falling (by up to a third from 2014 to 2035). 

For more facts and figures check out Cancer Research UK.

Risk factors

There are numerous risk factors, including age, smoking and occupational exposures.

  • Age
  • Smoking
  • Occupation and chemical associated exposures (e.g. arylamines, polycyclic aromatic hydrocarbons)
  • Chronic bladder infections/irritation
  • Medications (e.g.cyclophosphamide) 
  • Family history
  • Schistosoma haematobium (a significant risk factor in the development of bladder squamous cell carcinoma, this is common in many regions - for example Egypt and the middle east)

Clinical features

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

  • Haematuria (micro or macroscopic)
  • Dysuria
  • Urgency
  • Urinary frequency

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

Referral

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.

There are other triggers for referral for unexplained symptoms (e.g. weight loss, anorexia), and clinical judgement must be used.

Investigations

Cystoscopy is the diagnostic modality of choice.

Blood tests

  • FBC
  • UE
  • LFT

Urinary

  • Urine dip & MSU
  • Urinary cytology

Cystoscopy

The diagnostic standard, allows visualisation of the bladder and biopsies to be taken. May be diagnostic and therapeutic allowing TURBT to be completed.

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.

CT urogram and PET-CT may also form part of the staging work-up.

Staging

Bladder cancers are staged using the TNM classification system.

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. The full staging is beyond the scope of this note but can be found on this EAU page.

Bladder cancer is frequently divided into non-muscle-invasive bladder cancer and muscle invasive bladder cancer. The terms superficial and deep bladder cancer are no longer used.

Management

Management options are generally categorised based on the presence or absence of muscle invasion.

Non-muscle-invasive bladder cancer

NICE recommend categorising patients with non-muscle-invasive bladder cancer as low, medium and high risk. This is based primarily of the staging and grade of the tumour.

TURBT forms the cornerstone of management in non-muscle-invasive cases. During cystoscopy NICE recommend white-light-guided TURBT with photodynamic diagnosis, narrow-band imaging, cytology or a urinary biomarker test for suspected bladder cancer. 

Detrusor muscle should be obtained with TURBT, if not, repeat must be considered.

Numerous adjusts may be used. Those with intermediate risk disease may have a course of intravesical mitomycin C.

Patient with high risk disease will typically have a repeat TURBT within 6 weeks. They may 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.

Adjuvant chemotherapy with cisplatin may be given after radical cystectomy if muscle invasive disease is found on cystectomy histology.

All patient will need follow-up (determined by risk) to monitor for resolution and recurrence.

Muscle-invasive bladder cancer

Management is complex and dependent on numerous factors. Specialist urology MDTs should review each case to guide management.

In suitable patients neoadjuvant cisplatin chemotherapy may 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 patient will need follow-up tailored to their disease and management. 

Prognosis

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

The below figures are taken from Cancer Research UK.

  • 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.

Further reading

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