Bladder cancer

Bladder cancer is a malignant condition of the bladder. In most cases, it originates in the lining of the bladder, known as the urothelium.

• If the cancer cells are growing on the surface layers and if the tumor is limited to the bladder lining, this is known as non-muscle-invasive bladder cancer. 
• Tumors where the cancer cells spread to the muscle layer of the bladder wall are called muscle-invasive bladder cancers.  

When they’re first diagnosed, most bladder cancers have not yet spread to the muscle layer. 

Bladder cancer is difficult to detect. But the following signs are typical: 

• blood in the urine, usually not painful, sometimes with a reddish or brown discoloration of the urine
• symptoms when urinating, for example frequent urge to urinate with only small amounts of urine each time  

In the early stages, some patients have no symptoms, or only very general ones. Men may think the symptoms are prostate problems and women may think they have a bladder infection.

If unusual symptoms persist for a long time, the person affected is advised to go and see a doctor. General Practitioners can already narrow down what is causing the symptoms and, if necessary, initiate further diagnostic steps with specialists.

Smoking

The main risk factor for bladder cancer is active and passive smoking. If a smoker gives up smoking, the risk of them getting bladder cancer is reduced.

Chemical substances

But some chemical substances can also increase the risk of getting bladder cancer. Bladder cancer is recognized as an occupational disease for workers in occupational groups who are exposed to carcinogenic substances in their work. This affects painters and decorators, for example.

Inflammation

Bladder cancer is more common in people who have chronic inflammatory diseases of the bladder lining.  

Further information about the causes of and risk factors for bladder cancer can be found on the German Cancer Research Center’s Cancer Information Service website (in German).

There is currently no statutory cancer screening program for bladder cancer in Germany. 

There are commercial tests offered as an additional service. They are known as individual health services (“Individuelle Gesundheits-Leistung” – IGeL). But experts do not recommend these tests to screen for bladder cancer as their benefit has not been adequately clarified in studies. 

If they suspect someone might have bladder cancer, doctors perform the following tests: 

• Consultation (medical history) – one important thing for doctors to know is whether the patient smokes. 
• Physical examination
• Blood test
• Ultrasound (sonography)

Doctors can take additional measures to confirm the findings:

• Urine test to look for blood and cancer cells and, in some cases, for tumor markers
• Examination of the bladder (cystoscopy): with the patient under local anesthetic, the doctor passes a thin tube through the urethra of the person affected and into their bladder. A small camera on the end transmits images of the inside of the bladder onto a screen. Doctors can use this to identify changes in the bladder lining and take tissue samples (biopsy) from areas of suspicion. The tissue samples are then examined under the microscope in the laboratory.  
• Transurethral resection of the bladder (TUR-B): if the suspicion of bladder cancer is corroborated by these tests, a second, more comprehensive cystoscopy is usually performed with the patient under general anesthetic. During this cystoscopy, a rigid instrument is inserted and the suspicious tissue is completely removed with an electrical wire loop, if possible. Additional tissue samples may be taken and are also examined under the microscope in the laboratory. 

The following video explains how this surgical procedure is performed. How is a bladder tumor removed?

If the person has non-muscle-invasive bladder cancer with no risk factors, no further tests are carried out. TUR-B is also used as treatment in this case, as it removes the entire tumor. If there are risk factors and/or the person has muscle-invasive cancer, the doctor assesses the spread of the bladder cancer with tests that generate images of the inside of the body. These include: 

• computed tomography (CT)
• magnetic resonance imaging (MRI)
• chest x-ray

If bone metastases are suspected, experts recommend a bone scan (skeletal scintigraphy).

Do you want to know how a cystoscopy works and what other diagnostic tests there are? You can find detailed descriptions of the diagnostic tests used on the German Cancer Research Center’s Cancer Information Service’s website (in German). 

The layers of the bladder wall affected by bladder cancer differ with non-muscle-invasive and muscle-invasive bladder cancer. This means that the treatments also differ. The other important thing to consider is how aggressive the tumor is and whether the bladder cancer has already spread. 

Non-muscle-invasive bladder cancer 

If the cancer is superficial, the doctor can often remove the tumor completely during therapeutic cystoscopy. This procedure involves the urologists passing an electrical wire loop through a rigid tube into the bladder and removing the tumor using an electric current, with the patient under anesthetic. This procedure is called transurethral resection of the bladder (TURB).

With non-muscle-invasive bladder cancer there are often relapses. This is why experts recommend additional medication after the operation, which the doctor flushes into the bladder through a catheter and which have a local effect. Chemotherapy or treatment with the Bacillus Calmette-Guérin vaccine (BCG) are considered for use in this case. The BCG vaccine contains bacteria called immunomodulators that stimulate the immune system.

Since the muscle layer of the bladder is not affected by cancer, the bladder can be preserved for most patients. It is only if there is a particularly high risk of relapse that doctors recommend that the bladder is removed.

The aim of the treatment of non-muscle-invasive bladder cancer is to effect a complete cure.  

Muscle-invasive bladder cancer 

With muscle-invasive bladder cancer, the tumor has spread to the deeper bladder wall and possibly also the surrounding tissue.

Doctors usually remove the entire bladder. This operation is called radical cystectomy. This operation involves the surgeons removing the bladder and the neighboring lymph nodes. In women, the uterus, fallopian tubes, ovaries and parts of the vaginal wall are also removed and in men the prostate and seminal vesicle.

Patients who have muscle-invasive bladder usually also receive chemotherapy before or after surgery. Chemotherapy can reduce the risk of a relapse. Patients for whom chemotherapy is unsuitable may receive immunotherapy following surgery. As a prerequisite for this type of treatment, a specific biomarker must be detected in the tumor cells.

The bladder can sometimes be preserved, even in the case of muscle-invasive bladder cancer. Doctors recommend a transurethral resection (TURB) for these patients. This involves the tumor being removed as completely as possible. The operation is followed by radiotherapy and chemotherapy. The aim of the treatment is to cure the cancer.

If the bladder has had to be removed, the surgeons perform a procedure to give those affected an artificial form of urinary diversion to pass urine. The patients can have a discussion with the doctor to decide what form is best for them.

There are two basic forms of artificial urinary diversion: 

• dry (continent) urinary diversion and 
• wet (non-continent) urinary diversion. 

With continent urinary diversion, the urine is stored in a newly created reservoir and drained away. Doctors most often use the neobladder. This involves them using a piece of the small or large intestine to form a reservoir where the urine collects, situated where the removed urinary bladder was.

Over time, some patients with a neobladder are able to pass urine almost like they did with their healthy bladder. Others occasionally need a catheter that they insert into their bladder to divert the urine. 

With a non-continent urinary diversion, the urine flows continuously through an opening in the abdominal wall. For the most common procedure, the conduit, the surgeons use a piece of the bowel. They stitch this to one opening with both ureters and to the other with the abdominal wall. The opening in the abdominal wall is called a stoma. This is where they attach a removable pouch known as a stoma bag which collects the urine.

Metastatic bladder cancer

Once the cancer has spread, a cure is no longer likely. With these patients, the aim is to:  

• delay the progression of the disease for as long as possible.
• maintain their quality of life as much as is possible and relieve their cancer-related symptoms. 

At this stage of the disease, the bladder is usually no longer removed. Systemic treatment affecting the entire body is intended to stop the disease from progressing further. The following medication is considered, depending on the situation: 

• Chemotherapy uses medication (cytostatics) to stop cell growth or prevent cell division.
• Immunotherapy uses medicines to stimulate some of the body’s own immune cells to fight the cancer cells directly.
• Targeted therapies: drugs are used to target surface features of cancer cells. Healthy cells have few of these features or none at all.

The above-mentioned treatment options can have side effects.

Detailed information about how the treatments work, the side effects and coping with treatment complications with non-muscle-invasive bladder cancer and muscle-invasive bladder cancer can be found on the Cancer Information Service of the German Cancer Research Center’s website (in German).

Medical rehabilitation (rehab) after cancer treatment is intended to help patients recuperate. It also aims to help patients to deal with the effects of the disease and its treatment in the best possible way. This is why the rehab program is tailored to each person’s personal medical history and existing limitations. 
 
Urological rehab after bladder cancer treatment could include: 

• how to deal with a replacement bladder 
• how to deal with other forms of diversion, a stoma for example 
• help with digestive problems and with diet 
• how to deal with the effects of chemotherapy such as tiredness or nerve pain 

After the treatment, the doctors perform follow-up examinations, first at shorter intervals, then longer ones. They define the intervals between the examinations based on each affected person’s risk of relapse. 
 
Non-muscle-invasive bladder cancers have a high risk of relapse. Patients often relapse within five years of the treatment. This is why check-ups are very important. 
 
The doctors use the follow-up examinations to identify any complications of the treatment in good time. They can also detect a relapse early on and quickly start further treatment. The main follow-up examination is cystoscopy. The aftercare also includes urine and blood tests. 

The extent to which everyday life is altered after bladder cancer depends on how serious the cancer is and what treatments were required. 
 
If the bladder has been completely removed, the patient must expect problems with their sexual function and with passing urine.  
 
Patients with artificial urinary diversion can contact various specialists who deal with the effects of bladder cancer. These include, for example, specially trained nurses known as stomal therapy nurses, nutritionists and experts in the area of social work. Psychosocial support can make life with the disease easier.

Hospitals with a lot of experience in the treatment of patients with bladder cancer are called “Certified bladder cancer centers”.

You can find the addresses of the certified centers on the OncoMAP website.

Centers without certification may also offer a great deal of experience in treatment of patients with bladder cancer – for example, university hospitals with urological departments. 

Do you have further questions about dealing with the condition in everyday life and additional support options? You can find information about this on the Cancer Information Service of the German Cancer Research Center website (in German).

For all questions about bladder cancer, you can also make direct contact with Cancer Information Service doctors by dialing the freephone number (0800) 420 30 40 or by sending an e-mail to krebsinformationsdienst@dkfz.de.