• Diagnosis and Prognosis of Bladder Cancer

    Review of Medical History

    Your doctor will ask you about your smoking history, the kinds of jobs you have held that may have exposed you to cancer-causing agents, and information about your medical history (medications used, history of other types of cancer, past treatments with radiation therapy ). These areas of your history may help provide clues regarding your personal risk of developing bladder cancer.
    Your doctor will also question you about your current symptoms:
    • Have you noticed blood in your urine?
    • Do you have any urinary symptoms (increased desire to urinate, urinating more often, pain or burning when urinating)?
    • Do you have any abdominal (belly) or back pain?
    • Do you have any other new or unusual symptoms, such as increased fatigue, decreased energy, decreased appetite, weight loss, fever, swollen feet and/or legs, or bone pain?

    Physical Exam

    Your doctor will perform a complete physical examination. Special attention will be paid to the abdominal exam, checking to see if any mass can be felt and verifying any areas of tenderness or pain. Depending on your symptoms, your doctor may also do a vaginal, pelvic, or rectal exam, which entails manual probing in your abdomen, pelvis, and rectal area to determine whether there are masses that can be felt. These examinations may be a bit uncomfortable, but should not be painful.

    Diagnostic Testing and Cytology

    Urine tests will be done to check for the presence of blood, infection, or other abnormal cells. The cytology of urine cells will also be evaluated.
    Cytology is the study of cells. The cytology of cancer cells differs significantly from normal cells, and physicians use the unique cellular features seen on biopsy samples to determine the diagnosis and assess the prognosis of a cancer. Cytology testing of the urine will look for the presence of cancer cells and also help determine if the urine contains abnormal cells from the kidney or bladder, which might indicate cancer.
    Imaging Studies
    Your doctor may order a variety of imaging studies to verify the presence of a tumor in your bladder and to see if the tumor is causing any obstruction of the kidneys. Imaging studies that may be utilized include:
    • CT scan —This type of x-ray uses a computer to produce cross-sectional images of the inside of the body.
    • MRI scan —This test uses magnetic waves to produce images of the inside of the body. Using a large magnet, radio waves, and a computer, an MRI produces 2D and 3D pictures.
    • Intravenous pyelography —During this test, a dye is injected into one of your veins and a series of x-rays are taken. The dye courses through the urinary system, allowing x-ray pictures to be more clear and detailed.
    • Bone scan —A bone scan is done through injecting a radioactive material into the blood which will concentrate in areas of bone affected by cancer. Then, three hours later, you lie on a table. Special cameras move slowly above and below the table taking pictures. This allows the doctor to see areas of the bone that may contain cancer cells. If such areas are present, it means the cancer has spread beyond the bladder.
    Biopsy
    The doctor may remove a small sample of tissue, called a biopsy , from your bladder to test for cancer cells. A cystoscope will be inserted through your urethra and into your bladder. A cystoscope is a very small instrument with a long, flexible, and slender tube through which the doctor can see; this tube has a small light at the end to illuminate the interior of the bladder for inspection. During this procedure, the inside of your bladder can be examined and photographed.
    In addition, instruments can be passed through the cystoscope into the bladder to remove tiny samples of tissue (biopsies). These biopsies will be sent to the laboratory to check for the presence of cancer. Biopsy studies—particularly those that involve the whole removed tumor specimen—determine whether the tumor is confined to a small amount of tissue on a stalk (papillary), or whether it has invaded the wall of the bladder (nonpapillary). More invasive types of bladder cancer have a higher rate of metastasis, which means they are more likely to spread elsewhere in the body.
    If your doctor finds a suspicious tumor outside the bladder involving a lymph node, for example, a needle biopsy may be ordered. During this test, a small needle, guided by x-ray or other imaging techniques, is inserted into the lymph node. A sample of tissue is removed and examined under a microscope for the presence of cancer cells.
    Removal and Testing of the Cancer
    In many cases, it is important to surgically remove the cancer from the bladder. This may involve removing all or part of the bladder, including the wall, or it may involve removing only the cancer itself from the inside of the bladder, leaving the bladder otherwise intact. In such a situation, the cystocope is used to perform a transurethral resection of the tumor. “Transurethral” means that it is not performed with an open abdominal incision; instead, instruments are passed up the urethra and into the bladder, and the tumor is removed (resected) through the urethra.
    Results from this procedure will help the pathologist determine if your tumor is localized or whether it has begun to invade the bladder wall. While information from the removal of your bladder tumor is crucial to determining an appropriate treatment plan, it is also an important step in your treatment. If transurethral resection shows that the tumor has invaded the bladder wall, more extensive treatment, sometimes including additional surgery, can be planned.

    Staging

    Staging is the process by which physicians determine the extent of the disease or how far cancer has spread anatomically. This information and other factors, like the age and type of cancer cells, determine the prognosis. Staging is essential for making treatment decisions (eg, surgery vs. chemotherapy ). Several features of the cancer are used to arrive at a staging classification, the most common being the size of the original tumor, extent of local invasion, and spread to the local lymphatic and distant sites (metastasis). Low staging classifications (1-2) imply a favorable prognosis, whereas high staging classifications (3-4) imply an unfavorable prognosis.
    Staging Tests and Tumor Grading
    Staging bladder cancer involves a variety of diagnostic radiologic techniques, such as CT scan and MRI. On the other hand, grading is a microscopic description of the cancer cells, how they look under the microscope and the percentage of cells that appear to divide. Grading the tumor cells is an important prognostic factor particularly for certain types of tumor, like brain tumors. Faster growing, more invasive, more disorganized cells are assigned a higher and more serious tumor grade.
    Biopsy
    Biopsy studies will determine whether the tumor is confined to a small amount of tissue on a stalk (papillary), or whether it has invaded the wall of the bladder (nonpapillary). More invasive types of bladder cancer have a higher rate of metastasis, which means they are more likely to spread elsewhere in the body.
    Scanning Tests
    A variety of other studies may be done (or repeated), depending on whether your tumor is identified as superficial (confined to the inner lining of the bladder) or invasive (has spread into deeper tissues of the bladder, including the wall). If you have invasive bladder cancer, it is important to determine if your bladder cancer has spread to other parts of your body.
    Testing that may help reveal spread of your cancer into tissues and organs near your bladder or elsewhere in your body include CT scan, MRI, intravenous pyelography, and ultrasound examinations.
    Bone Scan
    A bone scan may be performed to see if the cancer is in your bones. For a bone scan, you'll receive an injection of a radioactive compound called technetium, which will concentrate in areas of bone affected by cancer. Then, three hours later, you lie on a table. Special cameras move slowly above and below the table taking pictures; these cameras detect small amounts of radioactivity in the injected technetium. This allows the doctor to see areas of the bone that may contain cancer cells. If such areas are present, it means the cancer has spread beyond the bladder and must be treated either locally (in the area it is found) or systemically (throughout the entire body). Systemic treatment in cancer is important because metastases (tumor that has spread outside the bladder) can exist for some time before it can be detected by scans and tests.
    Staging System for Bladder Cancer
    A simple staging system for bladder cancer is as follows:
    • Stage 0 : Cancer cells are only identified on the bladder’s inner lining. This is considered to be superficial bladder cancer (sometimes called carcinoma in situ).
    • Stage I : Cancer cells are identified in the bladder’s deeper tissues, but not in the bladder’s layer of muscle.
    • Stage II : Cancer cells can be found in the bladder’s muscles.
    • Stage III : Cancer cells have spread to the outermost layer of the bladder, and may have invaded the prostate (in men) or the cervix, uterus, or vagina (in women).
    • Stage IV : Cancer cells have spread to the tissue that lines the wall of the abdomen and/or pelvis. There may be cancer cells identified within lymph nodes and/or in distant locations, such as the liver, lungs, or bone.
    Stages of Bladder Cancer
    Stages of Bladder Cancer
    Copyright © Nucleus Medical Media, Inc.

    Prognosis

    Prognosis is a forecast of the probable course and/or outcome of a disease or condition. Prognosis is most often expressed as the percentage of patients who are expected to survive over five or ten years. Cancer prognosis is a notoriously inexact process. This is because the predictions are based on the experience of large groups of patients suffering from cancers at various stages. Using this information to predict the future of an individual patient is always imperfect and often flawed, but it is the only method available.
    When bladder cancer is diagnosed and treated in its earliest stages (stages 0, I, II), five-year survival is quite high—about 94%. After the cancer has spread within the pelvis (stage III), the five-year survival rate is only 49%, dropping to 6% once the cancer has spread to distant sites within the body (stage IV). Early detection and treatment is vital.

    References

    Campell’s Urology. 8th ed. New York, NY: Elsevier Science; 2002: 2732-2765.

    Cecil Textbook of Medicine. Philadelphia, PA: WB Saunders Company; 2002: 633-634.

    Conn’s Current Therapy. 54th ed. Philadelphia, PA: WB Saunders Company; 2002: 720-721.

    What you need to know about bladder cancer. National Cancer Institute website. Available at http://www.cancer.gov/cancerinfo/wyntk/bladder . Accessed December 2002.

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