What is Bladder cancer?
Bladder cancer is a common type of cancer that starts in the cells that make up the bladder, the organ that holds the urine. It occurs when cells that make up the lining become abnormal and start to grow out of control. Over time these cells form a tumor that can spread to nearby lymph nodes. This type of cancer typically affects older adults and is treatable when diagnosed early. One of the most common presenting symptoms is blood in the urine, this is called hematuria and approximately 85% of patients with the disease show signs of hematuria which is usually a result of direct hemorrhage of the tumor. Hematuria can be either microscopic (not visible to the naked eye but detectable with a urine test), or it can be gross hematuria (visible to the naked eye).
What are the risk factors?
Bladder cancer is most frequently diagnosed in people older than 65, but it can occur at a younger age. The prognosis (likely course of the disease), recurrence, progression, and death worsen with increased age. Smoking also increases the risk of bladder cancer by 2-3 times and risk increases more with longer and more intense smoking history. Second hand smoke also increases the risk. Other risk factors include exposure to chemical carcinogens, pelvic radiation, systemic chemotherapy, Schistosoma infection (a type of bladder infection), male sex (three times more like to get bladder cancer), chronic bladder inflammation (ex: UTIs, kidney/bladder stones, long-term catheter drainage, etc.), and genetic predisposition.
What are the presenting signs and symptoms?
Hematuria is the primary presenting symptom of bladder cancer, present in more than 80% of patients. The most common form of hematuria in bladder cancer is painless gross hematuria that is present throughout the entire urinary stream. Gross hematuria can be intermittent and therefore resolution of hematuria with antibiotics should not be perceived as a cure. Screening is therefore still indicated and important in all patients who experience gross hematuria.
Evaluation should also be considered in patients who experience microscopic hematuria, especially in the absence of other causes. Microscopic hematuria is defined as greater than or equal to 3 RBCs per high-power field. Renal and bladder ultrasound, urinalysis, urinary cytology, and cystoscopy are indicated if a benign cause of hematuria is not identified.
Dysuria (burning with urination) is typical in bladder cancer and it should be further evaluated in the absence of other causes or if it does not resolve after treating with antibiotics.
Frequency as a solitary symptom is rare in bladder cancer but it can occur. Benign prostatic hypertrophy (BPH) and overactive bladder are common causes of frequency but if these do not respond to treatment, urinary cytology and cystoscopy are indicated.
How is it diagnosed?
A urinalysis (UA) is typically the first test that is done. Hematuria is a typical finding in bladder cancer but it is not always present.
Urinary cytology is a urine test that looks for abnormal cells in the urine under a microscope. It is used along with other tests and procedures to diagnose urinary tract cancers. A FISH is usually added to the cytology test; it is a genetic test and it can increase the urine cytology sensitivity.
Cystoscopy is a procedure that uses a thin flexible tube with a light and camera that is inserted through the urethra in order to visualize bladder tumors and it also enables pathologic diagnosis. If bladder cancer is suspected, a biopsy is needed to be sure of the diagnosis.
CT abdomen and pelvis with and without contrast is also used in the evaluation of patients with gross hematuria. It can rule stones in/out and may reveal evidence of primary bladder cancer and/or metastatic disease
Cx Bladder test is a test that measures the gene expression levels of five biomarkers in urine that effectively rule out or detect the presence of bladder cancer.
A semen/urine culture is also usually ordered to help rule in/out infectious causes of hematuria.
If pathology reports indicate there is bladder cancer, additional tests are ordered in order to grade and stage the cancer and determine the best treatment method.
How is it treated?
Treatment is primarily guided by the tumor grade and stage and by additional imaging and laboratory findings as well as by the patient’s current health. It can range from removal of the tumor followed by chemotherapy to pre/post chemo-radiation, in combination with removal of the tumor, complete removal of the bladder, prostate, surrounding lymph nodes, and immunotherapy.
Screening for bladder cancer is not standard practice, but studies among populations with known risk factors suggest a survival benefit. If you have experienced hematuria or any of the above risk factors do not hesitate to schedule an appointment with The Y Factor to get your screening started.
American Urological Association. Diagnosis and treatment of non-muscle invasive bladder cancer: AUA/SUO joint guideline. 2020
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Cumberbatch MGK, Noon AP. Epidemiology, aetiology and screening of bladder cancer. Transl Androl Urol. 2019 Feb;8(1):5-11.
Fernández MI, Brausi M, Clark PE, et al. Epidemiology, prevention, screening, diagnosis, and evaluation: update of the ICUD-SIU joint consultation on bladder cancer. World J Urol. 2019 Jan;37(1):3-13.
Nielsen M, Qaseem A; High Value Care Task Force of the American College of Physicians. Hematuria as a marker of occult urinary tract cancer: advice for high-value care from the American College of Physicians. Ann Intern Med. 2016 Apr 5;164(7):488-97.
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Benancio Martinez Jr is a certified Family Nurse Practitioner and one of the newest integral parts of the Y Factor team. Benancio is the medical provider in charge of the Northpointe location and brings to the Y Factor 10 years of nursing experience obtained through the emergency departments of the VA and Kingwood medical centers, as well as clinical experience in family practice, hematology, and oncology.