Bladder Cancer

21.03.2024

BLADDER CANCER DIAGNOSIS AND TREATMENT

Bladder cancer is a type of cancer characterized by abnormal and uncontrolled growth of the cells that form the bladder surface. The bladder is a flexible organ located in the pelvic area and stores urine. Bladder cancer is treatable, especially when diagnosed at an early stage, and is commonly divided into three main types: Urothelial carcinoma (the most common type), squamous cell carcinoma, and adenocarcinoma. Urothelial carcinoma arises from urothelial cells lining the inner surface of the bladder. The most obvious symptom of bladder cancer is blood in the urine, and this condition is usually painless. Other symptoms may include frequent urination and a burning sensation when urinating. Risk factors include smoking, exposure to certain chemicals, chronic bladder infections, and bladder stones. Although the treatment of bladder cancer in the early stages is usually surgery, treatments such as chemotherapy, radiotherapy and immunotherapy may be required in advanced stages. The importance of this type of cancer is that due to its high recurrence rates and potentially invasive nature, regular monitoring and treatment is important. Early diagnosis, effective treatment, and ongoing monitoring can significantly improve patient health outcomes.

WHAT ARE THE RISK FACTORS?

There are many risk factors in the development of bladder cancer. These factors may increase the likelihood of the disease occurring:

Smoking: Smoking significantly increases the risk of developing bladder cancer. Smokers have a much higher risk of developing bladder cancer than non-smokers.

Chemical Exposure: The risk of bladder cancer may be increased, especially in people who work with industrial chemicals and certain dyes.

Chronic Bladder Infections and Inflammation: Long-term bladder infections or chronic inflammatory conditions (for example, interstitial cystitis) may increase the risk of bladder cancer.

Bladder Stones: People who have bladder stones may have an increased risk of developing bladder cancer.

Family History of Bladder Cancer: The risk may increase in people with a family history of bladder cancer.

Age: The risk of bladder cancer increases with age; In most cases, patients are over 55 years of age.

Gender: Men have a higher risk of developing bladder cancer than women.

Previous Cancer Treatment: Radiation therapy, especially to the pelvic area, or certain chemotherapy drugs (for example, cyclophosphamide) may increase the risk of bladder cancer.

Chronic Urinary Tract Obstructions and Catheter Use: Long-term use of urinary tract obstructions or indwelling catheters may increase the risk of bladder cancer.

Each of these risk factors alone does not cause bladder cancer, but having one or more of them may increase a person's overall risk. Quitting smoking, maintaining a healthy lifestyle and regular medical check-ups can help reduce the risk.

Image 1: Many factors such as age, smoking and chemical exposure play a role in the development of bladder cancer.

HOW DOES IT OCCUR?

Bladder cancer development mechanisms generally occur within a complex network of interactions. Major factors include smoking, chemical exposure (especially to substances such as aromatic amines), genetic predisposition, chronic irritation (bladder inflammation, infections), and the effects of certain medications or treatments. The combination of these factors can irritate the lining of the bladder, causing DNA damage and contributing to the formation of cancer cells. However, fully understanding the mechanisms of bladder cancer development is still a matter of research, and early diagnosis and management of risk factors are important.

WHAT ARE THE SYMPTOMS?

Symptoms of bladder cancer can be diverse and awareness is important for early diagnosis of the disease.

Common findings of bladder cancer:

Hematuria (Bloody Urine): The most common symptom is blood in the urine. This is usually painless and can make the urine pinkish, red or dark brown.

Frequent Urination: There may be an abnormal need to urinate frequently.

Pain or Burning Sensation While Urinating: You may experience discomfort such as pain or burning when urinating.

Difficulty Urinating: There may be difficulty urinating or a feeling of not being able to void completely.

Frequent Urinary Tract Infections: Recurrent or treatment-resistant urinary tract infections may occur.

Pelvic Pain: Constant or intermittent pain may occur in the lower abdomen.

Changes in Urine Flow: Weakening or intermittent urine flow may occur.

These symptoms do not always indicate bladder cancer and may indicate other health problems. However, it is important for people experiencing such symptoms to see a doctor for medical evaluation. Early diagnosis plays a very important role in the treatment of bladder cancer. Regular health checks and awareness of risk factors are important.

HOW IS IT DIAGNOSED?

Bladder cancer is usually diagnosed using symptoms, physical examination, imaging methods and laboratory tests. In the first stage, the patient's complaints and medical history are evaluated. Bladder cancer symptoms include changes in urine color, pain or burning when urinating, frequent urination, and bloody urine. During the physical examination, the doctor examines the abdomen and pelvis area. Imaging methods include computed tomography (CT), magnetic resonance imaging (MRI), and cystoscopy. CT and MRI help determine the size and spread of tumors, while cystoscopy is used to observe the inner surface of the bladder. If the diagnosis is confirmed, a biopsy is performed and the presence of cancer cells is confirmed as a result of laboratory examination. Bladder cancer diagnosis is a vital step in determining a patient's treatment options and prognosis.

WHAT ARE THE PATHOLOGICAL TYPES?

Pathological types of bladder cancer can be:

Urothelial Carcinoma (Transitional Cell Carcinoma): It is the most common type of bladder cancer and arises from the cells lining the inner surface of the bladder. These types of cancers are generally classified as superficial or invasive.

Squamous Cell Carcinoma: This type of cancer arises from squamous cells in the outer layer of the bladder wall. It is a more aggressive type and is usually diagnosed in advanced stages.

Adenocarcinoma: This type of cancer arises from gland cells that do not cover the inner surface of the bladder. Adenocarcinoma is generally a rarer type and may require different treatment approaches than other types.

Mixed Type: Some bladder cancers arise from more than one cell type and are called "mixed type." For example, urothelial carcinoma combined with adenocarcinoma.

These pathological types reflect different characteristics and treatment approaches of bladder cancers. Receptors that are important for determining the treatment plan and predicting the patient's response in bladder cancer are: PD-L1 (Programmed Death Ligand 1) and PD-1 (Programmed Death 1) receptors are important for assessing the response to immunotherapy and affect the response of the patient's immune system against cancer cells. . Additionally, the activity of FGFR (Fibroblast Growth Factor Receptor) receptors plays a role in some types of bladder cancer, and drugs targeting these receptors offer treatment options to control tumor growth. Analysis of these receptors helps patients achieve personalized treatment plans and receive optimal treatment.

Image 2: Bladder cancer may cause different complaints such as blood in the urine, frequent urination and painful urination.

HOW IS TUMOR STAGING DONE?

Staging of bladder cancer is used to determine the spread and severity of the disease and is usually done by the following methods:

Physical Examination: The doctor will evaluate the patient's symptoms and examine the abdominal and pelvic area.

Imaging Tests: Imaging methods such as computed tomography (CT) and magnetic resonance imaging (MRI) help evaluate the size, spread, and presence of the tumor.

Cystoscopy: This is an invasive procedure and is used to directly examine the inner surface of the bladder. A flexible tube (cystoscope) is inserted into the bladder and the doctor can observe tumors and perform a biopsy.

Biopsy: A biopsy is performed to confirm the tumor and determine its type. This is the process of taking samples of cancer cells.

Lymph node biopsy: Lymph nodes may also be biopsied to evaluate the spread of cancer.

The information used is used to determine the stage of bladder cancer. Using a classification published by the American Cancer Society, bladder cancer stages are generally determined as follows:

Stage 0: Cancer is limited only to the inner surface of the bladder.

Stage I: Cancer is limited only to the inner surface of the bladder.

Stage II: Cancer has reached the bladder muscle.

Stage III: Cancer has spread to the tissues or lymph nodes around the bladder.

Stage IV: Cancer has spread to distant organs (for example, the lungs or liver).

This staging system is important in determining the spread of the disease and treatment options. Treatment is determined depending on the stage of the patient's bladder cancer and health status.

HOW IS TREATMENT DONE ACCORDING TO STAGES?

Bladder cancer treatment may vary depending on the stage of the disease and other individual factors. Below is an overview of treatment approaches according to bladder cancer stages:

Stage 0 (Ta or Tis): At this stage, the cancer is limited only to the inner surface of the bladder. Treatment usually aims to remove the cancer locally. This surgery is sometimes accompanied by burning the tumor (resection) with electrocautery or laser, or injecting medications into the bladder, called intravesical treatments.

Stage I: The cancer is still limited to the inner surface of the bladder, but it may have penetrated deeper. Treatment may include radical cystectomy, which is surgery that involves removing part or all of the bladder. This procedure often involves removing lymph nodes as well. Alternatively, in some cases, radiotherapy of only the affected area or administration of medication into the bladder may be considered.

Stage II and Stage III: In these stages, cancer has spread to the bladder muscle wall or surrounding tissues. Treatment options may include radical cystectomy, surgery to the pelvic lymph nodes, and radiotherapy. Chemotherapy may also be used before or after surgery. In some cases, a combination of radiotherapy and chemotherapy (chemoradiotherapy) may be preferred.

Stage IV: At this stage, the cancer has spread from the bladder to organs distant from the bladder (for example, lungs, liver) or lymph nodes. Treatment usually involves systematic chemotherapy and surgery is not usually used at this stage. Radiotherapy or targeted drug therapies may also be considered to control local symptoms and improve the patient's quality of life.

Each patient's situation is different, and treatment options may vary depending on the patient's overall health, age, tumor biology, and other factors. To determine the best approach to bladder cancer treatment, a multidisciplinary approach is taken and patients are usually evaluated by an oncologist, urologist, and other specialists.

Image 3: In order to plan treatment for bladder cancer, staging is first done. In staging, factors such as spread to the bladder surface, spread to the lymph node, and distant organ spread are evaluated.

WHAT ARE THE DRUGS USED IN TREATMENT?

Chemotherapy, smart drug therapies and immunotherapies used in the treatment of bladder cancer may include:

Chemotherapy drugs:, A combination of Gemcitabine, Cisplatin and Gemcitabine can be used.

Smart Drug Therapies: FGFR inhibitors can be used in some types of bladder cancer, especially in patients with FGFR3 genetic mutations. Examples include Erdafitinib.

Immunotherapies: In bladder cancer, immunotherapy helps the immune system target cancer cells. Immunotherapy drugs may include: Pembrolizumab, Atezolizumab, Nivolumab

Treatment options may vary depending on the patient's stage of disease, genetic profile, and overall health. To determine the treatment plan, it is important for patients to collaborate with an oncologist and create a customized treatment plan.

HOW SHOULD FOLLOW-UP BE CARRIED OUT AFTER RECOVERY?

Follow-up after bladder cancer treatment is important to monitor the patient's health and detect possible recurrences or post-treatment complications early. The follow-up plan is usually determined depending on the stage of the patient's disease, the treatment used and the individual health condition. Typically, follow-up may include: regular doctor exams, urine tests, imaging (such as CT or MRI) studies, invasive procedures such as cystoscopy, measurement of tumor markers, and monitoring of symptoms. During follow-up, factors such as patients' lifestyle choices, non-smoking, healthy nutrition and regular exercise are also taken into consideration. A good follow-up program can ensure that patients live a healthy life and provide a more effective intervention by detecting possible relapses or complications early.