Bladder cancer: symptoms, diagnosis and treatment

Bladder cancer is a transversal disease that affects both men and women with a significant incidence in patients over 60.

According to the epidemiological curve, cases recorded every year in men are similar, which is a sign of plateau, while the first diagnoses of bladder cancer in women are growing, albeit slowly.

Italy: bladder cancer in numbers

In Italy, in 2020 (the last reference year before the pandemic), there were over 25,000 cases of bladder cancer, of which 20,000 in men and 5,000 in women. According to data from the Cancer Registry, 85% of this type of cancer is superficial, while in 15% of cases it is infiltrating (more dangerous).

Survival rate is estimated for 5 years and the possibility of a recurrence once cured is very high. The cancer reappears in 60-70% of cases, not always in a more severe form than the original tumor.

To date, 330,000 people have been diagnosed with bladder cancer, a considerable part of Italian population.

Surely the most important symptom to pay attention to is the presence of blood in the urine, or hematuria, which affects men and women. It is found, in fact, in 80-90% of those who have been diagnosed with bladder cancer.

Hematuria can be of the following type:

• macroscopic, i.e. visible to the naked eye,
• microscopic, detectable only through specific urine tests.

Other important symptoms, albeit less frequent, are irritative urinary disorders, such as:

• feeling of need to urinate often,
• presence of a very urgent stimulus,
• perception of having to urinate a lot and then, instead, expel a few drops.

Finally, some aggressive tumors that obstruct the outlet of urine from one of the kidneys can cause dull pain in the side, especially on one side of the back. These are sporadic and unusual signs of the disease.

There are various risk factors, such as:

• work: daily work in contact with dangerous substances with absence of adequate protection;
• environment: as in the case of schistosomiasis, an infection caused by a parasitic worm that lives in the fresh waters of subtropical and tropical regions;
• genetic: you may have a predisposition to this type of neoplasm, but not a genetic mutation.

One of the most predisposing factors, however, is certainly cigarette smoking which has a huge impact: it is present in 50% of cases.

“Harmful substances of a cigarette, after being filtered by the kidneys end up in the urine which, remaining in contact with the inner wall of the bladder, can cause cell mutations with the consequent formation of a neoplasm. The risk is proportional to the number of cigarettes smoked and years marked by this bad habit.

It should be noted that even passive smoking, unfortunately, exposes you to the risk of the onset of bladder cancer. With regard to electronic cigarettes, however, there are still no reliable data because much research are in the scientific validation phase,” – specifies the specialist.

To diagnose bladder cancer, there are first-level investigations, such as ultrasound, which is simple, minimally invasive, and precise, and urinary cytology, which consists of the collection of 3 urine samples on 3 different days.

If there is a diagnostic suspicion, it is good to move on to second-level investigations, such as CT (when there is a suspicion of involvement of the ureter or kidney) or cystoscopy which allows a direct diagnosis. Thanks to the introduction of flexible fiber optic cystoscopes a cystoscopy is much less invasive.

In any case, as for all neoplastic pathologies, the diagnosis must be prompt and early.

The most frequent form of bladder cancer is called urothelial which originates from the inner part of the bladder, from the skin that lines the bladder. However, the same skin also covers the ureter and a small part of the kidney so long-lasting back pain should not be underestimated.

Bladder neoplasms are almost always considered malignant and are divided into:

• high-grade form, which tends to be aggressive;
• low-grade, less aggressive form.

Rarer forms of bladder cancer are, however, associated with other factors such as schistosomiasis (as referred above) which causes squamous cell carcinoma fortunately rare in our latitudes.

Another important classification of bladder tumors, which can only be determined after their removal, is their separation between superficial and infiltrating.

The stagnation of this disease is fundamental because therapies, depending on the case, change radically.

Even if new drugs and new therapeutic protocols are being tested, treatment of bladder cancer are those of the past years.

At the Istituto Clinico Città di Brescia we tackle this pathology, like all neoplasms, with a multidisciplinary approach: oncologist and radiotherapist work side by side with urologist.

Following the first level diagnosis, we proceed with endoscopic resection of the bladder. It is a surgical practice thanks to which location of the tumor and number of bladder lesions are identified with camera equipped instrument, and which removed later using electric current.

Thereafter, based on the histological investigation, necessary to understand if it is a superficial or infiltrating neoplasm, following with the therapy.

In the case of a superficial tumor, therefore with fewer chances of recurrence, an intravesical chemotherapy or immunotherapy is preferred.

“It is the last frontier in the fight against cancer, which consists in taking a drug, containing a bacterium of tuberculosis, which is instilled in the bladder to stimulate patient's immune response. To date, this is the only therapy demonstrated capable of preventing the progression of bladder cancer,” Dr. Zani explains.

If, on the other hand, it is an infiltrating neoplasm, therefore of high risk, one inevitably proceeds with the total removal of the bladder: a demolition procedure that consists in removing the anterior pelvic organs (bladder, prostate and seminal vesicles in men; bladder, uterus, ovaries and anterior wall of the vagina in women).

The next step involves removal of the lymph nodes adjacent to the bladder which, in most cases, are the first site of metastasis. Once the bladder has been removed, urinary derivation takes place (internal or external) to ensure that the urine is brought out, effectively reconstructing the reservoir function that the bladder originally had.

“Adopting adequate lifestyles certainly helps, as does periodic screening and prevention checks from the age of 40 onwards,” explains Dr. Zani.

In the presence of symptoms, such as pain or frequent urination, it is advisable to perform an ultrasound and a urinary cytological examination, the one normally used to search for abnormal cells. If they give negative results or have normal values, it is likely that the symptoms are attributable to an infection, excluding more serious pathologies.