No wonder that hearing the word “cancer” terrifies us all. It is not easy at all to be diagnosed or even suspected to have cancer. 

When we hear this word, we think of chemotherapy, hair loss, weight loss, vomiting, and maybe death. We think of the long journey patients usually take to become cancer-free. And we all know perfectly well that it is a long and arduous journey for both the patient and those around him/her. 

Today, we are talking about urinary bladder cancer. 

The urinary bladder is the hollow muscular balloon shaped organ that is located in your lower abdomen and pelvis and stores urine that is produced from the kidneys until it is passed out of the body. 

Cancer is a disease that starts when some body cells start growing out of control, and when it happens in the urinary bladder it is called bladder cancer. 

According to The World Health Organization, bladder cancer is the twelfth most common cancer globally, with approximately 170,000 new cases each year; a third of these cases are in developing countries. 

Bladder cancer most often begins in the urothelial cells; the cells that line the inside of the bladder, also found in the kidneys and the ureters. Ureters are the tubes that connect the kidneys to the bladder. 

This urothelial cancer can also happen in the kidneys and ureters because these cells are found there too, but it is more common in the bladder than in the kidneys and ureters. 

But why, why does it happen in the bladder? What causes bladder cancer? 

Any type of cancer generally and bladder cancer specifically begins when there is a change, a mutation, that happens in the cell's DNA. 

A cell’s DNA has all the instructions that the cell should follow, it tells the cell what to do. When a mutation occurs, the DNA tells the cell to multiply rapidly and out of control, and to continue living beyond their life span when they, normally, should die. 

This abnormal growth of the cells forms a tumor. Over time, the tumor will grow larger and press on the surrounding healthy structures and invade other parts of the bladder, or worse it can spread to other body parts. 

Our bladders have different types of cells and each type can have malignant cells that can form a tumor. Where cancer begins, determines the type of bladder cancer and also determines the suitable treatment. 

There are three types of bladder cancer: 

• Adenocarcinoma. It begins in the cells of the bladder that secretes mucus, and it is a very rare type of bladder cancer. 
• Squamous cell carcinoma. It usually results from long-term irritation of the bladder cells. This irritation could be due to long-term use of a urinary catheter or chronic infection of the bladder. Squamous cell bladder cancer is rare in developed countries like the US, while it is more common in parts of the world where a certain parasitic infection, bilharziasis, is common. 
• Urothelial carcinoma. It is also known as transitional cell carcinoma and occurs in the cells lining the inside of the bladder as we mentioned earlier. Those urothelial cells expand and become thinner when the bladder is full, and they return to their normal size when the bladder is empty. Urothelial carcinoma is considered the most common type of bladder cancer. 

Some types of bladder cancer can be mixed, meaning that they might include more than one type of cells. 

And just like any type of cancer, there must be some risk factors that make certain populations at higher risk.

So, what are those risk factors? 

1. Smoking. When you smoke, either cigarettes, pipe, or even cigar, your body processes the chemicals in smoke and excretes them in urine. When these chemicals come in contact with the lining of the bladder, they cause irritation. They might also accumulate and damage the lining cells which increase your risk of getting bladder cancer. 
2. Old age. Although it can occur at any age, most people who are diagnosed with bladder cancer are 55 years old or more. 
3. Males are at higher risk to develop bladder cancer than females. 
4. Chronic bladder inflammation. Chronic bladder infection, inflammation (cystitis), or long-term use of a urinary catheter in certain health conditions will increase the risk of squamous cell carcinoma. 
5. Exposure to certain chemicals. The kidney is the organ responsible for filtering your bloodstream from any harmful or toxic chemicals and eliminating them in urine. It is thought that some chemicals are related to bladder cancer such as rubber, leather, and paint products. 
6. Family history of bladder cancer. If you had bladder cancer, it is more likely to occur again. If you have a blood relative that had bladder cancer, a sibling, a father, or a son you are at a higher risk of getting bladder cancer. It is rare for bladder cancer to run in families, but higher risks are real. 
7. Previous cancer treatment. People who received radiation treatment aimed at a tumor in the pelvis, or people who received chemotherapy, especially cyclophosphamide are at higher risk for bladder cancer. 
8. Bladder birth defects. Before birth, there is a connection between the belly button and the bladder, and it is called the urachus. If this connection remains, it might cause cancer. It is usually the adenocarcinoma type. About one-third of adenocarcinomas of the urinary bladder start due to this connection.  
9. Not drinking enough water. People who drink plenty of fluids every day, especially water, have a lower risk of developing bladder cancer. 
10. Arsenic in drinking water. It has been linked to a higher incidence of developing bladder cancer in some parts of the world. 

So, from these risk factors we conclude that if you are adopting any preventable risk factors such as smoking, you should stop it. And if you have unpreventable risk factors like age and family history, you should do a checkup and screening every now and then.

And if you have any suspicious symptoms, you should immediately see your doctor. 

But what are the symptoms that could be suggestive of bladder cancer? 

Bladder cancer signs and symptoms might include: 

• Blood in the urine, also known as hematuria. It is the most common symptom. Urine might appear bright red, or cola colored although it might be subtle that it is only detected in the lab. 
• Frequent urination. 
• Pain while urinating. 
• Back pain. 
• Pelvic pain. 

These symptoms can occur due to a variety of other conditions, and that’s exactly why it is important to check them with your doctor. 

The earlier you detect your cancer, the better the results of your treatment and the shorter your treatment journey will be. This is a gold piece of advice for any cancer patient. 

But can bladder cancer be found early?

It is sometimes found early when it is still small and doesn't spread. It gives patients better survival and treatment chances. 

Screening is the key, but it is only recommended for people who are at higher risk of developing bladder cancer. And those are: 

• People who had bladder cancer before. 
• People who had urinary bladder birth defects. 
• People exposed to certain chemicals at their workplace. 

Doctors can suspect from your history that you might develop bladder cancer, and thus, they would ask for certain investigations to eliminate that diagnosis or confirm it. 

These investigations include: 

• Urine analysis. It is the test used to check for blood in the urine. As we mentioned, blood in the urine can be a sign of a benign problem like infections, but it can also be a sign of cancer. That’s why your doctor might also ask for a urine culture, a test that can detect microbial infection, to rule out the probability of infection. 
• Urine cytology. In this test, doctors use a microscope to detect cancerous cells in the urine. It cannot detect all types of cancer, but it is reliable enough to detect some. 
• Urine tests for tumor markers. Some types of cancers produce certain substances that if detected in the blood or urine, it can tell that there is a tumor.  
• Cystoscopy. Inserting a small narrow flexible tube with a lens, light source and a camera at the end into the urethra allows your examiner to see the inside of the urethra and the bladder and examine them. 
• Tissue sample or biopsy. During a cystoscopy, the examiner might pass a small tool to collect a tissue sample so it can be examined in the lab for cancerous features. 
• Imaging tests. Such as CT urogram, X-rays or retrograde pyelogram, and MRI. They can detect and provide a detailed view of the urinary tract and they allow your doctor to identify any abnormality that might be cancer and if it has spread elsewhere. 

Our role today is to answer most of your questions regarding bladder cancer. Today we have Dr. Park, who is a leading doctor at Hanyang University Hospital in Seoul. He is going to discuss bladder cancer with us from an experienced medical point of view.

Interview

Ok, we will move onto bladder cancer. Just briefly, what is bladder cancer and what are the symptoms?

We are all familiar with bladders, as we always use it whenever we urinate. It is a pocket that stores the urine and with a pumping action, drains it out. When the urine itself becomes problematic and is stored in the bladder for a long time, that is how the cancer develops. So, bladder cancers would mostly occur inside the bladder where it comes in contact with urine. Therefore, bladder cancer symptoms tend to appear quickly.

But the problem is, because the symptoms can disappear by themselves, it can be easily ignored if you’re not careful. And this symptom is hematuria that has no pain. The urine contains blood but it is not painful.

Because there is no pain, you assume it is not a big deal and this blood can also disappear without treatment.

So, you might find blood in your urine and book an appointment at the hospital, but a few days later the bleeding stops and you end up not going because you think it’s all okay. But this is the first symptom of bladder cancer.

Once there is blood, you have to get an examination?

Absolutely, you must.

What kind of examination?

Most basically, a urine test that we do a lot when we have our regular medical examinations. Even if the blood in the urine is invisible to the eye, when we do a urine test, we examine it under a microscope. There should be no blood cells in the urine. We call it RBC – Red Blood Cell, and this should not be found in urine. But if this RBC is found in urine when seen under a microscope, we call this hematuria. So, if blood in urine is visible to the eye, we call it gross hematuria and if blood is found when examining under a microscope, we call this microscopic hematuria.

This can be an early symptom for many other diseases, including bladder cancer. So, a urine test must be done first and foremost. With a urine test, you can also see if there are any cancer cells. When we talk about endoscopy, we first think of gastroscopy and colonoscopy.

Like so, if bladder cancer is suspected or if there is bleeding, we can also do a bladder endoscopy called cystoscopy, by inserting a very thin tube through the urethra to check the bladder.

For example, what are the treatments that exist? Is it radiation, surgery or chemotherapy?

For bladder cancer, surgery is basically the primary treatment. But there are many different types of surgery. Because the bladder is used from 8 to 10 times a day for urinating, life is impossible without it. So unlike other cancers, we don’t do a surgery that removes all of the cancer in one go. If there is a lump, we first use an endoscope to cut off a little bit of it and if it hasn’t gone too deep, we continue cutting off pieces through repetitive endoscopy.

But if it has gone too deep and like for other cancers, we have no choice but to remove the whole bladder. If the cancer has developed past stage 3, just like other cancers, we also do chemotherapy and radiation therapy simultaneously.

Between men and women, who is more likely to get bladder cancer?

Bladder cancer is twice as common in men. Where I work, in the Department of Urology, there are twice as many men as patients, but also twice as often men developing cancer. Of course, prostate cancer patients are 100% men as women don’t get them. But other cancers such as kidney cancer, and bladder cancer have twice as many male patients.

In fact, bladder cancer is very closely related to cigarettes. When we smoke, various carcinogens are produced. And these carcinogens are excreted through urine. So, urine is directly affected by cigarettes. The longer this carcinogen-filled urine is stored in the bladder, the easier it is to develop bladder cancer.

In the old days, men smoked a lot more than women, so you could see the difference in genders. But these days, many women also smoke, so there has been an increase in female bladder cancer patients.

How about people who get cured after getting treatment? How often does it reappear?

If you remove the whole bladder, there is no need to come to the hospital often, as the cancer does not recur that well. But as I previously mentioned, the bladder is a very important organ for normal daily life. Even if the cancer has been removed through endoscopic surgery without removing the bladder, as the bladder is still there, it is easy for the cancer to recur.

So, in the early stage, we need to check if the cancer recurs or not by endoscopy every 3 months. But after 2 years, it is less likely for the cancer to recur, so we recommend checking twice a year.

Professor, can you tell us a bit about what urinary stone disease is?

In our bodies, we can develop stones in various places. There are two types of stones that people are familiar with. One is gallstones that are in the gallbladder. You’ve heard of it right?

Urine is produced from the kidneys, descends through the ureter, and is collected in the bladder, and then exits. During this whole process, whatever urine-related stone is produced, we call it a urinary stone.

Conclusion

We are all familiar with bladders, as we always use it whenever we urinate. It is a pocket that stores the urine and with a pumping action, drains it out. When the urine becomes problematic and is stored in the bladder for a long time, that is how the cancer develops. So, bladder cancers would mostly occur inside the bladder where it comes in contact with urine. Therefore, bladder cancer symptoms tend to appear quickly. But the problem is, because the symptoms can disappear by themselves, it can be easily ignored if you’re not careful.

The principal symptom is hematuria that has no pain. The urine contains blood, but it is not painful. Because there is no pain, many assume it is not a big deal and this blood can also disappear without treatment.

For diagnosis, a urine test during regular exams can tell a lot. Even if the blood in the urine is invisible to the eye, when we do a urine test, we can see if there is blood under a microscope. If cancer is suspected or if there is bleeding, we can do an endoscopy by inserting a very thin tube through the urethra to check the bladder.

For treating bladder cancer, surgery is basically the primary treatment. But there are many different types of surgeries. However, unlike other cancers, we don’t do a surgery that removes all of the cancer in one go. If there is a lump, we first use an endoscope to cut off a little bit of it and if it hasn’t gone too deep, we continue cutting off pieces through repetitive endoscopy.

Bladder cancer is twice as common in men. Also, bladder cancer is very closely related to cigarette smoking since various carcinogens are produced in the process