Bladder Cancer
with Ronald Tutrone, MD
What are the stages of bladder cancer?
Bladder cancer is the fourth most commonly diagnosed cancer and eighth leading cause of cancer death in the United States. According to Ronald Tutrone, MD, Chief of the Division of Urology at GBMC, patients have the best chance of successful treatment when the cancer is caught during its earliest stages.
The most significant risk factor for bladder cancer is smoking. “As a person is repeatedly exposed to carcinogens, it can cause his or her cells to mutate and become cancerous,” says Dr. Tutrone. “The longer the person is exposed, the greater his or her risk.” Those who are older in age, Caucasian, male or have repeated exposure to organic solvents or aniline dyes are at higher risk of developing bladder cancer.
Symptoms of the cancer include bloody urine, pain while urinating and frequent urination. The cancer is typically detected through a cystoscopy, which uses a fiber optic telescope to examine the bladder. Additional tests may include cytology, which looks for cancer cells within the urine and fluorescent insight to hybridization (FISH), which examines chromosomes within the urine for any abnormalities. It is also important for patients diagnosed with bladder cancer to have an upper urinary tract evaluation with a CAT scan or intravenous pyelogram.
The severity of bladder cancer is divided into four stages: Stage TA, Stage T1, Stage T2 and Stage T3. Stage TA cancer is superficial and is limited to the lining of the bladder. Stage T1 is when cancer has spread into the layer between the superficial lining of the bladder and outer muscular layer known as the lamina propia. Stage T2 is when cancer has progressed into the superficial muscle lining of the bladder. During Stage T3, cancer has spread into the deep muscle lining of the bladder.
Bladder tumors are graded by a pathologist according to how aggressive they appear under the microscope. The majority of tumors are transitional cell in origin but occasionally can be an adenocarcinoma or squamous cell carcinoma. Transitional cell tumors typically grow in the lower bladder neck and can cause partial or complete obstruction to urination. Adenocarcinoma is formed in the glands and squamous cell carcinoma is typically formed in thin, flat cells that are the result of long-term irritation or inflammation.
Treatment options depend on the stage of cancer. Stage TA cancer can be resected with an outpatient cystoscopy. During the treatment, the tumor is removed, similar to a polyp removal during a colonoscopy. Patients are then placed on surveillance with interval cystoscopies to assure there is no relapse. Patients with more advanced stages of bladder cancer or higher grade tumors are often treated with the cystoscopic resection, followed by intravesical chemotherapy. This involves the instillation of a chemotherapy agent such as BCG, alpha-intreferon or Mitomycin into the bladder with a catheter. The patient holds this for two hours. This is usually done once per week for six to eight weeks.
If the cancer has invaded the muscle wall of the bladder the only available treatment is cystectomy, which is the removal of the bladder and lymph nodes. This may be done with or without adjuvant systemic chemotherapy, which is when chemotherapy is delivered after treatment of the tumor. In the past, when the bladder was removed, patients were forced to wear an external urostomy bag. At GBMC, new technology allows some patients to avoid this inconvenience. “We are able to create a neobladder, which is when we make a new bladder out of a long segment of small intestine,” says Dr. Tutrone. “After we attach the segment to the urethra, the patient is able to urinate on their own without having to wear a bag.”
At GBMC, these innovative treatments are combined with a team approach. “We approach bladder cancer with multidisciplinary specialties,” says Dr. Tutrone. “Each team consists of a surgeon, entherostomal therapist, oncologist and radiology oncologist and everyone works together to decide how to best proceed with treatment.”
