Bladder cancer often presents with blood in the urine, but this is not always present or visible. Other symptoms include pain from the bladder region, burning on passing urine, or development of frequency or urgency. The symptoms are variable between individuals, and some patients may not have any symptoms in the early stages. When there is pain or discomfort, the symptoms can mimic urinary infection or cystitis. In women, similar symptoms can be misattributed to menopause. When blood is seen or identified in urine, the absence of pain or disappearance of symptoms is no reassurance that cancer is not present.
It is important that any suspicious bladder symptoms are properly investigated; otherwise diagnosis of cancer may be delayed and can become incurable.
Preliminary tests will look for non-visible blood or infection in the urine: these findings, particularly after the age of 40, indicate the need for further investigation, even if the original symptoms have settled.
Treatment of transitional cell carcinoma of bladder depends on whether or not there is invasion of the bladder wall muscle. 80% of tumours do not show invasion, and these can usually be cleared by shaving them from the bladder lining by an operation called transurethral resection of bladder. Nevertheless there is a tendency for this type of tumour to recur and for new tumours to develop, sometime lifelong. Regular assessment for recurrence and prompt clearance of any new tumours is therefore most important. These bladder assessments are usually done by flexible cystoscopy, initially on a 3 monthly basis, and later at increasing intervals the longer the remission.
When necessary, additional treatment can be used to reduce the rate of recurrence, in the form of bladder instillations with either chemotherapy or BCG solutions. Various possible options can be considered according to local availability, including:
These treatments are useful when a high likelihood of recurrence is anticipated, or when recurrences are frequent. Present evidence does not support there being any worthwhile reduction in the likelihood of progression by using intravesical therapies; this underlies the importance of regular monitoring for recurrences and clearing them by transurethral resection.
In addition to monitoring the bladder, the kidneys and the tubes draining them to the bladder (ureters) need periodic assessment; their lining can occasionally develop the same type of tumour as the bladder. For this reason, radiological assessments are undertaken at diagnosis and repeated according to the type of bladder tumour and its pattern of recurrence.
In some cases, more advanced and aggressive tumours develop in the bladder, with the potential to spread and grow elsewhere, as so-called metastases. For aggressive and invasive bladder tumours, more radical treatment options have to be considered, according to the extent of disease. This is assessed by CT scans of the chest, abdomen and pelvis. A bone scan may also recommended if there are skeletal abnormalities or symptoms.
Radical treatment options include major surgery to remove the bladder, called cystectomy, or radiotherapy; in some cases, chemotherapy can supplement these treatments, with modest additional benefit; chemotherapy is otherwise used for cancers that have spread beyond the proximity of the bladder. These treatments are best undertaken by a multidisciplinary team of urologists, oncologists and allied specialists working together with the individual.
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