for Bladder Cancer
If a patient has symptoms that suggest bladder cancer, the doctor will perform an evaluation that includes a complete physical exam and some lab tests. The physical exam may include a rectal or vaginal exam. In addition an outpatient procedure called a cystoscopy is usually used to diagnose bladder cancer. During a cystoscopy, the physician (a urologist) inserts a thin, lighted tube (cystoscope) into the bladder through the urethra to examine the internal lining of the bladder. The doctor can remove samples of tissue from the bladder with the cystoscope. A pathologist then examines the tissue under a microscope. The removal of tissue to look for cancer cells is called a biopsy. A biopsy is the only sure way to tell whether cancer is present. For a small number of patients, the doctor removes the entire cancerous area during the biopsy. For these patients, bladder cancer is diagnosed and treated in a single procedure.
When bladder cancer is diagnosed, the urologist will want to learn the stage or extent of the cancer, as well as the grade (aggressiveness) of the cancer as determined by its appearance under the microscope. Grade is important because it indicates how closely the cancer resembles normal tissue and suggests how fast the cancer is likely to grow. Low-grade cancers more closely resemble normal tissue and are likely to grow and spread more slowly than high-grade cancers.
Precision Medicine & Personalized Bladder Cancer Care
The purpose of precision cancer medicine is not to categorize or classify cancers solely by site of origin, but to define the genomic alterations in the cancers DNA that are driving that specific cancer. Precision cancer medicine utilizes molecular diagnostic & genomic testing, including DNA sequencing, to identify cancer-driving abnormalities in a cancer’s genome. Once a genetic abnormality is identified, a specific targeted therapy can be designed to attack a specific mutation or other cancer-related change in the DNA programming of the cancer cells. Precision cancer medicine uses targeted drugs and immunotherapies engineered to directly attack the cancer cells with specific abnormalities, leaving normal cells largely unharmed. Precision medicines are being developed for the treatment of cervical cancer and patients should ask their doctor about whether testing is appropriate.
When diagnosed with bladder cancer further tests are necessary to determine the extent of spread (stage) of the cancer. Cancer’s stage is a key factor in determining the best treatment. The stage of bladder cancer may be determined at the time of diagnosis or it may be necessary to perform additional tests.
Imaging tests: Tests such as X-rays, CT scans, magnetic resonance imaging (MRI) and positron emission tomography (PET) are used to help determine the stage and whether the cancer has spread beyond the bladder.
- Computed Tomography (CT) Scan: A CT scan is a technique for imaging body tissues and organs, during which X-ray transmissions are converted to detailed images, using a computer to synthesize X-ray data. A CT scan is conducted with a large machine positioned outside the body that can rotate to capture detailed images of the organs and tissues inside the body.
- Magnetic Resonance Imaging (MRI): MRI uses a magnetic field rather than X-rays, and can often distinguish more accurately between healthy and diseased tissue than a CT. An MRI gives a better picture of cancer located near bone than does CT, does not use radiation, and provides pictures from various angles that enable doctors to construct a three-dimensional image of the cancer.
- Positron emission tomography (PET): Positron emission tomography scanning is an advanced technique for imaging body tissues and organs. One characteristic of living tissue is the metabolism of sugar. Prior to a PET scan, a substance containing a type of sugar attached to a radioactive isotope (a molecule that emits radiation) is injected into the patient’s vein. The cancer cells “take up” the sugar and attached isotope, which emits positively charged, low energy radiation (positrons) that create the production of gamma rays that can be detected by the PET machine to produce a picture. If no gamma rays are detected in the scanned area, it is unlikely that the mass in question contains living cancer cells.
Intravenous pyelogram: (IVP) is a procedure which involves the injection of dye (contrast) into the blood. When the contrast travels through the kidneys and ureters, it allows these organs to be visualized with X-rays (fluoroscopy).
Urine tests: The laboratory checks the urine for blood, cancer cells, and other signs of disease. The most common urine test for bladder cancer is a urine cytology, similar to a Pap test.
Cystoscopy: The doctor uses a thin, lighted tube called a cystoscope to look directly into the bladder. The doctor inserts the cystoscope through the urethra to examine the lining of the bladder. The patient may need anesthesia for this procedure.
Stages of Bladder Cancer
Determining the stage and genomic profile of the cancer determines what treatment options exist. Cancers confined to the inner lining of the bladder are called “superficial” and comprise 70-80% of all bladder cancers. Cancers that have spread into the bladder wall are called “deep” bladder cancers and those that have spread to lymph nodes and/or distantly to lungs, liver or other organs are referred to as “metastatic.”1,2
Stage 0 (T0): Patients with stage 0 bladder cancer have the earliest stage of cancer that involves only the innermost layers of cells in the bladder. Depending upon the appearance of the cells under the microscope, stage 0 transitional bladder cancer is pathologically classified as either noninvasive papillary carcinoma or carcinoma in situ (CIS), both of which are considered to be “superficial” bladder cancers.
Stage I (T1): Patients with stage I bladder cancer have cancer that invades beneath the surface of the bladder into connective tissue, but does not invade the muscle of the bladder and has not spread to lymph nodes. This is also classified as a “superficial bladder cancer.”
Stage II (T2): Patients with stage II bladder cancer have cancer that invades through the connective tissue into the muscle wall, but has not spread outside the bladder wall or to local lymph nodes. Patients with cancer invading the inner half of the muscle of the bladder wall have a better outcome than patients with invasion into the deep muscle (outer half of the muscle of the bladder wall). Stage II bladder cancer is classified as a “deep” or “invasive” bladder cancer.
Stage III (T3): Patients with stage III bladder cancer have cancer that invades through the connective tissue and muscle and into the immediate tissue outside the bladder and/or invades the prostate gland in males or the uterus and/or vagina in females. With stage III bladder cancer, there is no spread to lymph nodes or distant sites. Stage III bladder cancer is also classified as a “deep” or “invasive” bladder cancer.
Stage IV (T4): Patients with stage IV bladder cancer have cancer that has extended through the bladder wall and invaded the pelvic and/or abdominal wall and/or has lymph node involvement and/or spread to distant sites. Stage IV bladder cancer is also referred to as “metastatic” bladder cancer. Recurrent Bladder Cancer: Patients with recurrent bladder cancer have cancer that has returned following initial treatment with surgery, radiation, chemotherapy or immunotherapy.
Recurrent: Patients with recurrent bladder cancer have cancer that has returned following initial treatment with surgery, radiation, chemotherapy or immunotherapy.
Next: Treatment & Management
1 Pashos CL, Botteman MF, Laskin BL, Redaelli A. Bladder Cancer: Epidemiology, Diagnosis, and Management. Cancer Practice 2002;10:311-322.
2 National Cancer Institute. Bladder Cancer (PDQ®): Treatment. Health Professional Version. Available at: http://www.cancer.gov/cancertopics/pdq/treatment/bladder/HealthProfessional