Bladder cancer, although not a very common cancer in Malaysia, can be a very aggressive tumour in the later stages of the disease and may lead to psychosocial distress due to the need for surgical intervention.
It occurs more frequently in males than in females, and is, in fact, the sixth most common cancer among males in Malaysia.
Agewise, this cancer tends to mostly affect those aged 65 years and above.
The good news is that about seven out of every 10 bladder cancers are diagnosed at a very early stage, when it is treatable.
The bad news is that there is as high as a 70% chance of recurrence, therefore survivors need to be followed-up for many years to see if the cancer returns.
For advanced bladder cancer, a major surgery with bladder removal and urinary diversion is needed for treatment, which often causes psychosocial distress to the patient.
The risk factors for bladder cancer are smoking and exposure to chemicals used in dye factories, latex (especially for rubber tappers), leather, textiles, printing, plastics, paints and other chemical industries.
In clinical practice, the most common risk factor is smoking.
Repeated inflammation of the bladder from untreated bladder stones and radiotherapy to the pelvis can also result in this cancer.
Unfortunately, some people with bladder cancer have no obvious risk factors.
When to see the doctor
Bladder cancer signs and symptoms can include:
- Blood in urine (haematuria)
- Painful urination
- Pelvic pain
- Back pain
- Having to urinate more than usual
- Feeling the urge to urinate even if the bladder is not full
- Lower back pain on one side
- Weak urine stream
- Fatigue and weakness
- Loss of appetite and weight
The most common complaint doctors usually hear is painless blood in the urine.
If you have this symptom, you should ideally see a urologist within two weeks of your symptoms occurring.
The urologist will assess your kidneys, ureter and bladder through an intravenous urogram (IVU) or a CT (computed tomography) scan, followed by an endoscopic examination of your bladder through your urinary passage (a cystoscopy).
The cystoscopy is relatively painless, although there may be some discomfort, and can easily be done with local anaesthesia.
Even if the blood in your urine goes away, you should still meet the urologist for a proper assessment.
This is as this symptom is not always a persistent one, and your next episode of blood in the urine may occur very much later when the bladder cancer is already in an advanced stage.
Blood in the urine does not always indicate bladder cancer though.
It may occur due to stones, infection, benign vascular malformation and various other causes.
However, bladder cancer should always be ruled out first before assuming this symptom is due to other causes.
Staging to treat
Proper staging of the bladder cancer is required before deciding on treatment.
Bladder cancer may be broadly staged as superficial disease, muscle invasive disease and advanced disease, depending on how many layers of the bladder wall have been invaded.
Superficial disease is highly treatable without needing to remove the bladder.
Known as TURBT (transurethral resection of bladder tumour), this treatment involves inserting a cystoscope through your urethra into your bladder to remove the tumour.
Chemotherapy or other medications might then be passed into the bladder for local treatment.
Unlike intravenous (IV) chemotherapy, the chemotherapy instilled into the bladder does not cause nausea, loss of hair, loss of appetite or loss of weight, and is very well tolerated.
Superficial bladder cancer, in most instances, requires life-long follow-up and surveillance in case the cancer recurs.
Muscle invasive disease, on the other hand, has a high risk of progressing to advanced disease.
Removing the bladder and its surrounding lymph nodes at this stage is a vital part of treatment to prevent spread of the disease and to achieve cure.
This surgery is among the most complex urological operations, with considerable morbidity and prolonged hospital stay.
Complications after bladder removal have been reduced in the current era, mostly due to improved operative techniques, better anaesthetic management and evolution of perioperative medical care.
Aside from surgery, there are various other options for treatment, including radiotherapy, radio-chemotherapy and partial removal of the bladder.
However, these are reserved for a small group of patients who have multiple medical illnesses and are not fit for surgery.
The cure rate for these patients is lower than those who undergo surgical treatment.
After the bladder is removed, it needs to be substituted with a urinary conduit or a reservoir.
This can be achieved by utilising a part of the small or large intestines and remodelling it into a conduit or a reservoir that is connected to the urinary tract system.
Those who prefer an intestinal conduit will have a stoma placed in the abdominal wall where their urine can exit into a urostomy bag.
Those who prefer a neobladder will have the option of not having any stoma as the neobladder acts as a reservoir connected to the ureters and urethra, allowing for voluntary urination.
Advanced disease occurs when the cancer has spread to the liver, lungs, distant lymph nodes and/or bones, among other organs.
In these cases, cure may not be achieved, but chemotherapy and the newer targeted agents, including immune checkpoint inhibitors, can help prolong life.
It should also be noted that the bladder’s inner lining, known as the urothelium, is a continuous lining from the kidneys above to the ureter, bladder and urethra below.
Thus, a person with bladder cancer may also harbour cancer deposits in the kidney, ureter and the urethra simultaneously, or may have a recurrence in these areas during follow-up later.
Prevention and myths
There are a few ways to reduce the risk of bladder cancer:
- Stop smoking
Smoking is the biggest and most common risk factor for bladder cancer.
- Beware of chemicals
If you work with chemicals, follow all safety instructions to avoid exposure.
And follow the necessary protocols in occupational screening for cancers.
- Secondary prevention
If you have blood in the urine, either visible or identified during urine microscopic examination, see your urologist within two weeks of discovering the symptom.
Even if it goes away, you should still meet the urologist for a proper assessment.
Blood in the urine is the most common symptom of bladder cancer and should not be ignored.
You can achieve a reasonably high cure rate if bladder cancers are diagnosed early.
There are also a number of common myths, misconceptions and inaccuracies surrounding the issue of blood in the urine and bladder cancers:
- Antibiotics will help
The presence of blood in the urine does not imply that a course of antibiotics should be tried with the hope that the blood in the urine will disappear.
The blood may disappear, but the cancer will not.
Antibiotics are only indicated for urinary infection, based on the symptoms and suspicion of an infection.
Painless blood in the urine requires immediate referral to the urologist, and not a trial of a course of antibiotics.
- Water will clear it
Drinking more water with the hope of clearing the blood in the urine will not clear the cancer away.
- Traditional medications are a cure
Traditional and herbal medications will not cure or reduce bladder cancers.
- Bladder cancer is contagious
Bladder cancer is not contagious and will not spread to other family members or people close to the patient.
- Chemotherapy side effects are horrible
The local instillation of chemotherapy into the bladder for superficial bladder cancers will not give the bad side effects of regular IV chemotherapy.
Dr Rajeentheran Suntheralingam is a senior consultant urologist. For more information, email firstname.lastname@example.org. The information provided is for educational purposes only and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.