(Test Bank) Bladder Cancer

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100 Questions & Answers About Bladder Cancer Second Edition Pamela Ellsworth, MD Associate Professor of Urology/Surgery The Alpert School of Medicine at Brown University Providence, RI Brett Carswell, MD Chief, Division of Urology Fallon Clinic Worcester, MA95870_FMxx_FINAL.QXP 7/16/10 12:05 PM Page iJones & Bartlett Learning books and products are available through most bookstores and onlinebooksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com.World HeadquartersJones & Bartlett Learning40 Tall Pine DriveSudbury, MA 01776978-443-5000info@jblearning.comwww.jblearning.comJones & Bartlett Learning Canada 6339 Ormindale WayMississauga, Ontario L5V 1J2CanadaJones & Bartlett Learning International Barb House, Barb MewsLondon W6 7PAUnited Kingdom Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available tocorporations, professional associations, and other qualified organizations. For details and specificdiscount information, contact the special sales department at Jones & Bartlett Learning via theabove contact information or send an email to specialsales@jblearning.com. Copyright © 2011 by Jones & Bartlett Learning, LLC All rights reserved. No part of the material protected by this copyright may be reproduced orutilized in any form, electronic or mechanical, including photocopying, recording, or by anyinformation storage and retrieval system, without written permission from the copyright owner.The authors, editor, and publisher have made every effort to provide accurate information.However, they are not responsible for errors, omissions, or for any outcomes related to the useof the contents of this book and take no responsibility for the use of the products and proce-dures described. Treatments and side effects described in this book may not be applicable to allpeople; likewise, some people may require a dose or experience a side effect that is not describedherein. Drugs and medical devices are discussed that may have limited availability controlled bythe Food and Drug Administration (FDA) for use only in a research study or clinical trial.Research, clinical practice, and government regulations often change the accepted standard inthis field. When consideration is being given to use of any drug in the clinical setting, thehealthcare provider or reader is responsible for determining FDA status of the drug, reading thepackage insert, and reviewing prescribing information for the most up-to-date recommenda-tions on dose, precautions, and contraindications, and determining the appropriate usage for theproduct. This is especially important in the case of drugs that are new or seldom used.Production CreditsExecutive Publisher: Christopher DavisEditorial Assistant: Sara CameronAssociate Production Editor: Leah CorriganAssociate Marketing Manager: Katie HennessyManufacturing and Inventory Supervisor: Amy BacusComposition: Glyph InternationalCover Design: Colleen LamyCover Images: (Top) © Kuzma/ShutterStock, Inc., (Bottom left) © Monkey BusinessImages/ShutterStock, Inc., (Bottom right) © PT Images/ShutterStock, Inc.Printing and Binding: Malloy, Inc.Cover Printing: Malloy, Inc. Library of Congress Cataloging-in-Publication DataEllsworth, Pamela. 100 questions & answers about bladder cancer / Pamela Ellsworth, Brett Carswell. p. cm. — (100 questions & answers) Includes bibliographical references and index.ISBN 978-0-7637-9587-0 (alk. paper) 1. Bladder—Cancer—Popular works. 2. Bladder—Cancer—Miscellanea. I. Carswell, Brett. II. Title. III. Title: Hundred questions & answers aboutbladder cancer. IV. Title: One hundred questions & answers about bladder cancer. RC280.B5E456 2011616.99'462—dc22 2010023518 6048Printed in the United States of America14 13 12 11 10 10 9 8 7 6 5 4 3 2 195870_FMxx_FINAL.QXP 7/16/10 12:05 PM Page iiContents Preface v Part 1: The Basics 1 Questions 1–20 give background information on the bladder and cancer, including: • What is the bladder, and what does it do?• Can I live without my bladder?• What is cancer? Part 2: Diagnosis 27 Questions 21–37 discuss the diagnosis of bladder cancer, including: • What are the signs and symptoms of bladder cancer?• Are there other conditions that can cause hematuria?• My doctor suspects I have bladder cancer. What tests will I need? Part 3: Treatment 53 Questions 38–48 describe treatment options, including: • What is a TURBT?• What are the risks of TURBT?• What is perioperative chemotherapy? Part 4: Intravesical Therapy 63 Questions 49–61 discuss this therapy in detail, including: • What is intravesical therapy?• What is the difference between therapeutic and prophylactic intravesical therapy? • What is immunotherapy? Part 5: Surgery 73 Questions 62–88 describe surgical options, including: • What is a radical cystectomy?• Who needs a radical cystectomy?• Should I have chemotherapy before having a radical cystectomy?95870_FMxx_FINAL.QXP 7/16/10 12:05 PM Page iiiPart 6: Nonoperative Therapy 111 Questions 89–91 discuss options that do not include surgery, including: • What is bladder-sparing therapy?• What are the risks of bladder-sparing therapy?• What is gene therapy, and is it available for bladder cancer patients? Part 7: Metastatic Disease 117 Questions 92–97 describe where and how your cancer can spread, including: • How does bladder cancer spread outside of the bladder?• If bladder cancer does spread, where in my body will it go?• Are there any blood tests to check for the spread of bladder cancer? Part 8: End-of-Life Care 125 Questions 98–100 discuss preparing for end-of-life care, including: • I have never thought of dying before, but now that I have been diagnosed with bladder cancer, I find myself wondering, are there things that I should do to prepare for death? • If aggressive treatment is too much to bear or seems futile, is it okay to stop treating my cancer? Appendix 131 Glossary 135 Index 147 iv100 QUESTIONS & ANSWERS ABOUT BLADDER CANCER95870_FMxx_FINAL.QXP 7/16/10 12:05 PM Page ivThis book is dedicated to our patients with bladder cancer, bothyoung and old, whom we have treated over the years. Their courage,triumphs, tragedies, and needs have inspired us to write this book. There is a sudden silence when a doctor mentions the word cancer. This silence is soon fol lowed by a flood of emotions. These include sadness, fear, anxiety, helplessness, guilt, and frustration.Despite these overwhelming emotions, patients and their familiesare expected to quickly process the diagnosis and make major deci-sions regarding treatment. Often a 30-minute or 60-minute discus-sion with the doctor is all that transpires before choosing treatment, which may include major surgery. This may be an overwhelming orfrightening time and many questions are never asked. Questionslike, how will surgery affect my sexual function? Will I be able todo the same things that I did prior to surgery? Will people know Ihave a urine bag? These questions often take a backseat initially toquestions regarding the bigger issues at hand, such as will surgerycure me of my bladder cancer? What happens if the cancer hasspread outside of my bladder? And can I live without a bladder?Many patients turn to friends, family, or the Internet for information.While these sources can be helpful, they may not always be accurateand often reflect a single unique experience. This book is designedto answer the questions most commonly asked by our patients withbladder cancer. It is our hope that this book will serve as a r esource for people with bladder cancer and their families to help them betterunderstand the disease and the treatment options.Preface95870_FMxx_FINAL.QXP 7/16/10 12:05 PM Page v95870_FMxx_FINAL.QXP 7/16/10 12:05 PM Page viThe Basics What is the bladder, and what does it do? Can I live without my bladder? What is cancer? M o r e ...PART ONE95870_PT01_FINAL.QXP 7/2/10 1:03 PM Page 11. What is the bladder, and what does it do? The bladder is the container in the body that stores urine. The other term for bladder is “vesical,” which isderived from the Latin word vesicular. The bladder is asoft, round structure that is located in the pelvis. The pubic bone is in front of the bladder; the rectum in men or the uterus in women is behind the bladder. Urine drains into the bladder through an opening oneach side at the bottom of the bladder. Urine is storedin the bladder until a person is ready to urinate. In orderto urinate, the muscle in the bladder wall squeezes, push-ing the urine out of the bladder through the urethra.I n women, the urethra is short, only approximately 1 inchlong. In men, it is much longer because it has to passthrough the prostate and then the penis before finally opening at the tip of the penis.In the middle of the abdomen, just beneath the lowerribs, are the kidneys. The kidneys filter the blood toproduce urine. The urine that the kidneys produce exitsthe kidney through the renal pelvis and flows into the ureters. The ureters are soft, muscular tubes that areabout the width of a pencil. They carry the urine fromthe kidneys down to the bladder, where they open intothe base of the bladder.The adult bladder normally holds approximately 400 mlof urine. The bladder wall has three separate layers.The innermost layer that is in contact with the urineis a thin layer called the urothelium. The middle layer is made of muscle fibers that can squeeze. When themuscles contract, they increase the pressure inside thebladder, squeezing the urine out of the bladder. Theoutermost layer is a thin but protective layer called serosa (Figure 1). 2100 QUESTIONS & ANSWERS ABOUT BLADDER CANCER Bladder The hollow organthat stores and discharges urine from the body. Pelvis The part of the bodythat is framed by thehip bones. Uterus The muscular pelvicorgan of the femalereproductive systemin which the fetusdevelops. Urethra The tube throughwhich one urinates. Prostate A gland within themale reproductivesystem that is locatedjust below the bladdersurrounding part ofthe urethra, the canalthat empties thebladder; produces afluid that forms partof semen.Rectum The last portion ofthe large intestinethat communicateswith the sigmoidcolon above and theanus below.95870_PT01_FINAL.QXP 7/2/10 1:03 PM Page 2The bladder has two functions. The first is the storageof urine, and the second is the emptying of urine. In aninfant, the bladder constantly fills and empties withoutany control by the brain. During toilet training, thebrain learns to control the bladder, enabling it to hold(store) the urine until a time when it is socially accept-able to urinate. Emptying is the second function thatthe bladder must perform. In infancy, before toilet train-ing, this is actually the most important function of thebladder.Although most of us take these two processes forgranted, either one or both can malfunction. If the stor-age function fails, the bladder can become very small andcontracted, holding just a tiny amount of urine before itneeds to empty. In contrast, it may become floppy anddilated, holding several liters of urine before it is ready toempty. It can also become “overactive,” causing feelings ofurgency and the need to urinate more than eight times per day. When the actual emptying function goes wrong, 3100 QUESTIONS & ANSWERS ABOUT BLADDER CANCER Kidneys Ureters Ureteropeningsintobladder PenisUrethraProstateBladder Figure 1 The male urinary tract. Source: Illustration by Laura Tritz, reprinted by permission from cancerfacts.com, copyright 2004.Renal pelvis The area at the centerof the kidney. Urinecollects in the renalpelvis and is funneledinto the ureter. Ureters Muscular tubes thatconnect the kidneys tothe bladder, throughwhich urine passesinto the bladder. Urothelium The cells lining thewall of the bladder,ureter, and the col-lecting system of thekidney. Serosa One of the delicatemembranes of con-nective tissue thatline the internal cavities of the body. Urgency The complaint of asudden compellingdesire to void that isdifficult to defer.Abdomen The part of the bodythat is below the ribsand above the pelvicbone; it containsorgans such as theintestines, the liver,the kidneys, thebladder, and theprostate.95870_PT01_FINAL.QXP 7/2/10 1:03 PM Page 3the bladder may only partially empty each time, leaving ahigh remaining amount of urine (the so-called postvoid residual). The bladder muscle may also weaken to thepoint where one is completely unable to urinate. This iscalled urinary retention . When storing urine, the bladder must do so at a lowpressure. This allows the new urine made in the kidneysto flow downward into the bladder. A safe bladder pres-sure is less than 40 cm H 2O. When the pressures are higher than this, the urine may “back up” in the kidneys.High pressures in the kidneys over a long period of timemay damage the kidneys. During urination, the bladdermust squeeze to force the urine out. The pressure in thebladder at these times may be much higher than 40 cmH 2O, but it does not usually damage the kidneys. This is because the pressure is elevated for just a short timeand then quickly returns to normal. 2. Can I live without my bladder? Yes. You can live without a bladder. However, you stillneed something that can perform the two basic func-tions of the bladder: storing and emptying of urine.Physicians have come up with many ways over theyears to accomplish these tasks, many of which are stillused today. The simplest alternative is to place drainagetubes into the kidneys that come out through the skinand connect to bags on the abdomen. These tubes areknown as nephrostomy tubes. Nephrostomy tubes aretypically inserted into a person in the X-ray departmentby an interventional radiologist who uses some light sedation. For the patient, the bag provides an easy wayto store urine and can be drained several times a daywhen convenient by opening a small valve on the bag.These tubes can be uncomfortable, however, and mayalso be easily removed if tugged; therefore, they are 4100 QUESTIONS & ANSWERS ABOUT BLADDER CANCER Postvoid residual The volume of urineleft in the bladder atthe end of micturition. Urinary retention The inability to uri-nate, leading to adistended bladder. Nephrostomy tube A tube placedthrough the back into the kidney thatallows for drainage of urine from thatkidney. Interventional radiologist A radiologist who spe-cializes in minimallyinvasive, targetedtreatments performedusing imagery forguidance.95870_PT01_FINAL.QXP 7/2/10 1:03 PM Page 4only reasonable solutions for a short period of time orfor patients who are too ill to undergo surgery. It is alsopossible to surgically bring the ureters directly to theskin sur face (called a cutaneous ureterostomy ). The urine then can be collected with a bag attached to the skinaround the opening. Unfortunately, the ureters are rela-tively small, and thus any scarring or narrowing of theopening can c ause a blockage of urine. This tendency to get blocked also makes cutaneous ureterostomies a poor long-term solution.To provide a good long-term solution, surgeons mostcommonly use a portion of the small bowel to act as thenew bladder. The identified piece of small bowel isremoved from the main portion and is fashioned for itsnew use (see Question 79 for details). The urine thatcollects within this piece of bowel will ultimately bedrained in one of three ways. First, the bowel can simplybe left open at the skin for the urine to drain passivelyout into a bag that is attached to the abdomen. This typeof drainage is known as a conduit, and the opening onto the skin is called a urostomy. Urine collects in the bag, which is then drained into a toilet several times each day.Second, the bowel can be sewn into a rough sphere con-nected to the skin by only a small, long channel. Thischannel prevents urine from leaking out but easilyaccommodates a small catheter. This is called a conti- nent urinary diversion . With this type of diversion, you must pass a catheter into the new bladder several times aday to drain the urine. This allows you to live without anostomy bag , but for some patients, passing the catheter several times a day may be difficult or impossible. Third,the new bladder can be directly reattached to the urethra(called an orthotopic neobladder). This allows you to urinate almost normally, although you do need to learnto use different muscles, as the new bladder replacement 5100 QUESTIONS & ANSWERS ABOUT BLADDER CANCER Ureterostomy Surgical formation ofan opening in theureter for drainage ofthe urine; in a cuta-neous ureterostomy,the ureteral orifice isbrought through theabdominal wall onthe skin. Conduit A method of divert-ing the urine flow byconnecting theureters—the tubesthat drain the kidneys—to a segment of intestinethat is closed at oneend. The open end issewn to the abdomi-nal wall to allow forurine to drain into acollecting bag. Urostomy A conduit for thedrainage of urinefrom the kidneys tothe anterior abdomi-nal wall. May bemade from small orlarge intestine. Catheter A hollow tube thatallows for fluiddrainage from orinjection into anarea.95870_PT01_FINAL.QXP 7/2/10 1:03 PM Page 5is not able to contract on its own. This is an excellentoption for some people, but it is a longer, more difficultoperation with some risk of incontinence. For more details on these procedures and more discussion aboutwhich option may be right for you, see Question 80. 3. What is cancer? To understand cancer, we must first understand nor-mal functioning of the body. The body is made up ofbillions of cells. Each organ of the body is made up of several different types of specialized cells. For example,the liver has cells that filter toxins from the blood, andthe brain has nerve cells (called neurons) that are able to conduct electrical signals. Perhaps the most familiarcells are skin cells. Every flake of dry skin is made ofmillions of cells that are constantly dying and beingreplaced with new cells. The growth of new cells is care-fully balanced to occur at the same rate as the death ofold cells. Your body has many mechanisms in place toregulate the timing of the birth and death of cells.Unfortunately, if one of these mechanisms malfunc-tions, the careful balance can be disrupted. Environ-mental toxins such as cigarette smoke, chemicals, andradiation can damage DNA and can disrupt these control mechanisms. A tumor may develop when new cells are created faster than old cells die. Tumors canbe either benign or malignant. A benign tumor is an overgrowth of cells that is unchecked by the body’snormal mechanisms; thus, it will keep getting bigger.It is called benign because it does not cause you illness.Some benign tumors can get to be so large that they docause problems, especially if they are in a confinedspace, such as your skull. A malignant tumor is also anovergrowth of cells. The tumor is considered malignant,however, because the cells are no longer confined to thetumor. Cells may spread from the main tumor through 6100 QUESTIONS & ANSWERS ABOUT BLADDER CANCER Risk The chance or proba-bility that a particularevent will or will nothappen. Incontinence, urinary The involuntary lossof urine.Continent urinary diversion A form of urinarydiversion that is ableto store urine. Theurine is emptied sev-eral times a day byplacing a catheterinto a small channelthat connects theconduit to theabdominal wall andallows the urine todrain through thecatheter. Ostomy bag A specialized bagthat is applied overan ostomy to collecturine and stool. Orthotopic In the normal orusual position. Neobladder An artificial/newbladder, created byusing a portion of theintestines, that storesurine like a real blad-der and allows one tourinate per urethra.95870_PT01_FINAL.QXP 7/2/10 1:03 PM Page 6the blood and lymph system or grow directly into nearbystructures. As the cells begin to grow unchecked in neworgans, they gradually cause dysfunction all over thebody and may eventually even cause death. 4. What is bladder cancer? Bladder cancer is a malignant overgrowth of the cellsof the bladder. Most commonly, the growth occurs incells that are in the urothelium. The lining of mosthollow spaces in the body is made of epithelial cells. The lining of the inside of your cheek, for instance, is anepithelial cell lining. Also, the lining of your stomach,bowels, gallbladder, and—you guessed it—the bladder is made of epithelial cells. Each organ has its own subsetof epithelial cells. In the bladder, the lining cells arecalled transitional epith elial cells. The c ancer that grows from these cells is then called transitional cell cancer;90% to 95% of all bladder cancers are of this type. Ifthe cancer grows from a different type of cell in thebladder, it is given a different name. Other types ofuncommon cancers in the bladder include squamous cell carcinoma and adenocarcinoma (carcinoma is another word for cancer). A very rare type of bladder cancer thatoccurs only in children is called rhabdomyosarcoma. It is also possible that cancer in the bladder did not beginthere but spread to the bladder from somewhere else.The bladder is an uncommon place for other tumors to“seed” (or metastasize), but it does occasionally occur. Although metastases are uncommon, tumors can occa-sionally grow directly into the bladder from an adjacentorgan, such as the prostate, colon, rectum, or cervix. 5. How common is bladder cancer? Cancer is one of the major causes of death and disease throughout the world. If all types of cancer are com bined, 7100 QUESTIONS & ANSWERS ABOUT BLADDER CANCER Cell The smallest unit ofthe body. Tissues inthe body are made of cells. Organ Tissues in the body(i.e., heart, bladder)that work together toperform a specificfunction. Nerve A cord-like structurecomposed of a collec-tion of nerve fibersthat conveysimpulses between apart of the centralnervous system andsome other region ofthe body. Radiation The application ofenergy in the form ofrays or waves to treatvarious medical conditions. DNA The basic buildingblock of cells. It car-ries the cell's geneticinformation andhereditarycharacteristics.Cancer Abnormal anduncontrolled growthof cells in the bodythat may spread,injure areas of thebody, and lead todeath.95870_PT01_FINAL.QXP 7/2/10 1:03 PM Page 7it ranks as the second leading cause of death in theUnited States today behind heart disease. As treatmentsfor heart disease continue to improve, it has been esti-mated that within the next 5 to 10 years cancer willbecome the leading cause of death in the United Statesand other developed countries.Bladder cancer is the fourth most common type ofcancer in men and the eighth most common in women.The American Cancer Society estimated that in 2009,there would be about 70,980 new cases of bladder cancerdiagnosed in the United States. In 2009, 14,330 deathswere expected from bladder cancer. In spite of theincreased incidence of bladder cancer over the years, the rate of people dying from bladder cancer has decreased over the past 20 years.From 1998 to 2000, the median age at diagnosis was 63 years of age. 90% of patients were 55 years of age andolder at the time of diagnosis. The chance of a mandeveloping bladder cancer at any time during his life isabout 1 in 27, whereas it is 1 in 84 for a woman. Thusbladder cancer is 3 times more common in men than in women. The incidence of bladder cancer increases withage in both sexes, meaning that an older individual ismore likely to acquire bladder cancer than a youngerperson. It is twice as common in white American menas it is in African American men and 1.5 times morecommon in white American women as it is in AfricanAmerican women. Hispanic Americans also have abouthalf the rates of bladder cancer as do white Americans.Bladder cancer is more common in the United Statesand Great Britain than in Japan or Finland.In most patients (74%), at the time of diagnosis, thecancer is confined to the bladder. Although bladder 8100 QUESTIONS & ANSWERS ABOUT BLADDER CANCER Benign A noncanceroustumor that canexpand and press onsurrounding struc-tures but does notinvade surroundingstructures and doesnot spread to a distant site. Malignant A cancerous tumor;can invade surround-ing structures andspread to a distant site. Epithelial cells Cells that cover thesurface of the bodyand line its cavities. Gallbladder A digestive tractorgan that storesbile, a chemical pro-duced in the liver. Squamous cell carcinoma Of the bladder, a typeof cancer that typicallyoccurs in chronicallyinflamed bladders,such as occurs in indi-viduals with chronicindwelling catheters.Tumor An abnormalswelling or mass.95870_PT01_FINAL.QXP 7/2/10 1:03 PM Page 8cancer is more common in white Americans, AfricanAmericans tend to have more advanced disease whenthey first present to the doctor. This may be because ofan underreporting of more superficial tumors, delays in diagnosis, or a tendency toward more aggressivetumors in this group. As would be expected from thetendency toward more advanced disease, 5-year survivalrates are 71% for African American men versus 84% forwhite men, and 71% for African American women ver-sus 76% for white women. 6. Are there different types ofbladder cancer? Yes. There are two broad types of cancers in the bladder:primary and metastatic. Primary bladder cancers arethose that begin in the bladder itself. Metastatic cancersare those that originated in another organ and thenspread to the bladder. Other tumors can get into thebladder through the bloodstream, through the lymphatic system, or by directly extending from a nearby organ,such as the prostate or the cervix.Cancers originating in the bladder are far more commonthan cancers that spread to the bladder from another loca-tion. There are several types of primary tumors. Recallthat transitional cell cancer accounts for at least 90% ofall bladder cancers. Transitional cell tumors can be classi-fied as (1) papillary , (2) sessile, or (3) a mix of both types. Papillary tumors look like a piece of cauliflower attached to the wall by a short stalk; sessile tumors look flat andare broad-based. Almost 70% of transitional cell tumorsare papillary types, which tend to have a better prognosis than sessile tumors. Less common types of bladder can-cer include squamous cell cancer, adenocarcinoma, andurachal carcinoma. 9100 QUESTIONS & ANSWERS ABOUT BLADDER CANCER Carcinoma The lower, narrowend of the uterusthat connects to thevagina. Rhabdomyo- sarcoma A malignant tumorderived from striatedskeletal muscle. Metastasize Describes when acancerous tumor hasspread to a distantsite, for example, thebones, the liver, orthe brain. Cervix The lower, narrowend of the uterusthat connects to thevagina.Colon The large intestine.Adenocarcinoma A form of cancer thatdevelops from amalignant abnormal-ity in the cells lining aglandular organ; aless common form ofcancer of the bladder. Disease Any change from orinterruption of thenormal structure orfunction of any partor organ system ofthe body that pre-sents with character-istic symptoms andsigns, whose causeand prognosis maybe known orunknown.95870_PT01_FINAL.QXP 7/2/10 1:03 PM Page 9Squamous cell carcinoma accounts for 3% to 7% ofbladder cancers in the United States; however, in Egyptit accounts for 75% of the bladder cancers. There is aparasitic infection called schistosomiasis that is very common in Egypt. Infection with this parasite strongly predisposes a person to the development of squamouscell cancer. The parasite burrows into the wall of thebladder, which chronically irritates the bladder. Overmany years, this chronic irritation can lead to the devel-opment of bladder cancer, most often squamous cellcancer. Other conditions that cause chronic irritationalso predispose to this type of tumor. Chronic i ndwelling catheters, for example, can irritate the bladder and pre-dispose someone to this tumor. Squamous cell carci-noma does not tend to spread to the lymph nodes like transitional cell cancer does, although it does tend tospread aggressively directly through the bladder intoneighboring structures. Because it is so locally aggres-sive and relatively resistant to chemotherapy or radia- tion, it usually has a worse prognosis than transitionalcell cancers.Adenocarcinoma of the bladder is quite uncommon,accounting for approximately 2% of all bladder cancersin the United States. These tumors are also associatedwith chronic irritation. They tend to be high-gradeaggressive tumors and are therefore usually associatedwith a worse prognosis.Urachal carcinoma is a specific type of adenocarci-noma of the bladder, but it is unique in that it does notoriginate in the lining of the bladder. These developfrom the outer surface of the bladder, extending towardthe inside of the bladder. They can then metastasize tothe lymph nodes, the liver, lung, and bone. 10100 QUESTIONS & ANSWERS ABOUT BLADDER CANCER Incidence The rate at which acertain event occurs. Diagnosis The identification ofthe cause or presenceof a medical problemor disease. Superficial Near the surface. Lymphatic system The tissues andorgans (the bonemarrow, spleen, thy-mus, and lymphnodes) that produceand store cells thatfight infection andthe network of ves-sels that carry lymph. Prognosis The long-term out-look or prospect forsurvival and recoveryfrom a disease.Papillary Related to bladdercancer, a bladdercancer that has astalk with nipple-likeprojections. Sessile Pertaining to bladdercancer, a cancer thatis broad-based andstalkless.95870_PT01_FINAL.QXP 7/2/10 1:03 PM Page 107. What causes bladder cancer? Cancer, including bladder cancer, develops because ofchanges in the DNA of a normal cell. DNA can bedamaged by chemical exposures such as cigarette smoke,industrial chemicals, chemotherapy, and so forth. (SeeQuestions 10 and 11.) Environmental exposures suchas these are called risk factors. Risk factors do not exactly cause bladder cancer. Not everyone who smokes willget bladder cancer. However, as a group, the risk is ele-vated relative to people who do not smoke. Exposuressuch as these increase the likelihood of DNA becom-ing damaged. When the specific DNA that controls acell’s growth is damaged, the cell then has the poten-tial to become cancerous. The hallmark of cancer isovergrowth of cells, causing compression of surround-ing tissues or destruction of the tissues. 8. Can I do anything to avoid getting bladder cancer? Absolutely! Some risk factors, such as your genes,c a n -not be changed. Many more, however, can be changed.Cigarette smoking is the biggest risk factor for gettingbladder cancer. If you are a smoker, the most impor-tant thing you can do is to quit today. If someone youlive with smokes, encourage that person to quit also.Question 10 discusses what are called modifiable riskfactors. These are the lifestyle and enviro nmental things that you can change to decrease your chances of get-ting bladder cancer. Look over this list carefully, anddo everything you can to change your lifestyle now tohelp protect your future and your family’s future. 11100 QUESTIONS & ANSWERS ABOUT BLADDER CANCER Lymph node A small bean-shapedorgan that is part ofthe immune system;nodes filter out bacteria or cancercells that may travel through the lymphatic system.Parasite An organism thatobtains food andshelter from anotherorganism.Schistosomiasis A parasite that is a“fluke” or “worm.”Associated withincreased risk ofbladder cancer.Urachal carcinoma Cancer that developsin the urachus. Althoughclassified as a bladdercancer, this cancerdevelops outside ofthe bladder and growsinto the bladder. Chemotherapy A treatment for can-cer that uses power-ful medications toweaken and destroythe cancer cells. Tissue Specific type of material in body, forexample, muscle,hair.95870_PT01_FINAL.QXP 7/2/10 1:03 PM Page 119. What are my risk factors for bladder cancer that I cannot change (unmodifiablerisk factors)? As we alluded to previously here, not everyone has thesame risk of developing cancer. By studying the charac-teristics of patients who have bladder cancer, researchershave been able to identify groups of people who seemto develop the disease more often than others. Thesegroups of people each have some risk factor that theyare born with, things that predispose them to cancer nomatter how carefully they live their lives. In fact, ourgenetic makeup probably plays the biggest role in deter- mining who among us is destined to get cancer. Race: Different races have different risks of bladder cancer. Caucasian (white) Americans are twice aslikely to develop transitional cell cancer (the mostcommon type of bladder cancer), as are AfricanAmericans. For the more rare type of bladder cancer,called squamous cell cancer, however, the reverse istrue; African Americans are twice as likely todevelop squamous cell cancer of the bladder thanare white individuals. Of all the different races,Caucasians seem to have the highest rate of bladdercancer.Gender: Men are almost three times more likely to develop cancer than women. This is before takinginto consideration modifiable risk factors such assmoking and workplace exposures to chemicals.Age:More than 65% of bladder cancer occurs in patients who are older than 65. Patients in this agegroup are also more likely to develop more aggres-sive tumor types than are the younger bladdercancer patients. 12100 QUESTIONS & ANSWERS ABOUT BLADDER CANCER Genes Located in thenucleus of the cell,genes contain hered-itary information thatis transferred fromcell to cell. Lifestyle The way a personchooses to live. More than65% ofbladder canceroccurs inpatients whoare older than 65.95870_PT01_FINAL.QXP 7/2/10 1:03 PM Page 12Genetics: As you may remember from the prior dis- cussion, cancer develops only after something goeshaywire in the regulatory process of cell growth orcell death. Several different genes normally accom-plish this regulation. In a normal, healthy cell, thesegenes promote growth or suppress growth or caneven signal a cell to destroy itself in an appropriatesituation. For a cell to become cancerous, many ofthese genes must be altered or destroyed simultane-ously. Nature has even supplied our cells with othergenes that are able to repair damaged genes. These“repairmen” genes are known as tumor suppressor genes. Their job is to repair damaged DNA whenpossible or to drive a damaged cell to destroy itself. The net result of these processes is to strike a balance ofnew cell growth and old cell death. You can imagine thatif there were damage to the process that removes cells,then these cells would begin to accumulate. If manyother cells also were missing this signal, they might alllive too long, causing an overgr owth of cells that we refer to as a tumor. If the cells simply accumulate, then wecall the tumor benign. If the cells are able to escapefrom the main tumor and begin to accumulate in otherorgans, we refer to the tumor as malignant.Fortunately, nature is not so easily beaten, and thereare multiple redundant systems to regulate these cellcycles. For cancer to develop, there needs to be damageto multiple systems at the same time. When cancer runsin a family, it is usually because damage to one or moreof these systems is present already, making it much eas-ier to have a failure of regulation later in life. Examplesof these genes are the p53 gene or the retinoblastoma(Rb) gene. Damage to p53 is a common genetic changein all types of cancers. 13100 QUESTIONS & ANSWERS ABOUT BLADDER CANCER Genetics A field of medicinethat studies heredity. Tumor suppressor genes A group of genes thatact to slow down thegrowth/developmentof a cancer/tumor.95870_PT01_FINAL.QXP 7/2/10 1:03 PM Page 13Although these systems normally provide tight regula-tion of cell growth, your body does not always wanttight regulation. Sometimes cells need to be able toreproduce quickly without the constraints of the regula-tory genes. Examples of this include the healing phaseafter an injury or surgery, or during normal growth inchildhood. To accommodate these situations, there areother genes in each cell that when activated allow thecell to grow more vigorously. When you break a bone,new bone cells need to move in quickly and replace thedamaged tissue. Your body then needs a way “take offthe brakes” to allow growth of certain cell types. Acommon signal to “hit the accelerator” is called epider-mal growth factor and is often abnormal in bladder cancer, especially in more aggressive tumors. Thesetypes of genes are known as oncogenes. A gene named the p21 ras oncogene can be found in many bladder cancers. Although oncogenes are not well understood,they may play a role in determining how aggressively atumor behaves. They appear able to change a low-gradetumor into a higher-grade, more aggressive tumor.Researchers are always identifying new genes and newproteins that are involved in bladder cancer, and each new finding provides a possible route of new therapy toprevent or treat bladder cancer. 10. What are the risk factors for bladdercancer that I could change? There are several known risk factors for bladder cancer.By far the biggest cause of bladder cancer in theUnited States is cigarette smoking. Other risk factorsare exposure to aniline dyes , recurrent urinary tract infec- tions, chronic foley catheters, bladder stones, and previ- ous radiation to the pelvis as treatment for another c ancer. Also, there may be a small increased risk for peoplewho color their hair with permanent hair colors, with 14100 QUESTIONS & ANSWERS ABOUT BLADDER CANCER Epidermal growth factor A chemical that stim-ulates growth of cells. Oncogenes Genes that canpotentially induceneoplastic transfor-mation (develop-ment of cancer). p21 ras oncogene A specialized onco-gene that has beenassociated with can-cers in humans. Proteins Any group of com-plex organic macro-molecules thatcontain carbon,hydrogen, oxygen,nitrogen, and usuallysulfur and are com-posed of alpha-amino acids. Proteinsare fundamentalcomponents of all living cells andinclude many substances such asenzymes, hormones,and antibodies thatare necessary to thefunctioning of anorganism. Aniline dyes A class of synthetic,organic dyes obtainedfrom aniline (coaltars). These dyeshave been used toimpart color to paper,cloth, and leather,and have been usedin woodworking.95870_PT01_FINAL.QXP 7/2/10 1:03 PM Page 14the risk increased in those people who dye their hairmore often or who started coloring it at a younger age.Dietary factors may also affect the risk of bladder cancer.In a review of data from the Surveillance, Epidemiol-ogy, and End Results database, it was found that patients with other primary tumors had a tenfold higher risk ofbladder cancer compared with the general population.The risk was highest in patients who were previouslydiagnosed with prostate cancer. Infection of the bladderby a parasite called schistosomiasis markedly increasesthe risk of bladder cancer. Although this infection iscommon in Egypt and surrounding countries, it is rarein the United States. Tobacco: Cigarette smoking accounts for 25% to 65% of all cases of bladder cancer in the UnitedStates. It increases the risk of bladder cancer by upto four times compared with someone who hasnever smoked. As you might expect, the risk increases as the number of cigarettes increases,the number of years of smoking increases, and bythe degree of inhalation with each puff. This appliesto both men and women. The risk is even higherwith the use of air-cured “black” tobacco because ithas a higher concentration of chemicals than flue-cured “blond” tobacco. The good news is that quit-ting smoking decreases your risk; thus, it is nevertoo late to quit. Other forms of tobacco, such ascigars and smokeless tobacco, also increase the riskof cancer, although to a lesser degree. It is not clearwhat chemical in the cigarette smoke is responsiblefor bladder cancer. Some people clear the chemicalsfrom cigarette smoke more slowly than others do.These people, called slow acetylators, appear to beat increased risk for bladder cancer. 15100 QUESTIONS & ANSWERS ABOUT BLADDER CANCER Urinary tract infection Infection of the uri-nary tract withmicroorganisms. It may involve thebladder (cystitis)and/or the kidney(pyelonephritis). Foley catheter A catheter that isplaced into the bladder via the urethra to drainurine. Slow acetylator Someone whometabolizes certainchemicals slowerthan others do.95870_PT01_FINAL.QXP 7/2/10 1:03 PM Page 15Occupational risk factors: Exposure to aniline dyes is the most common industrial risk factor for bladdercancer. Aniline dyes are byproducts of burning coal.These dyes have been used for staining or coloringwood and textiles. Other occupational chemicals thathave also been associated with bladder cancer include2-naphthylamine, 4-aminobiphen yl, 4-nitrobiphenyl, 4-4-diaminobiphenyl (benzidine), and 2-amino-1-naphthol, certain aldehydes used in rubber and textilemanufacturing, combustion gases and soot from coal,and possibly hydrocarbons. An increased risk hasbeen reported in all of the following occupations:autoworker, painter, truck driver, drill press operator,leather worker, metal worker, machine operator, drycleaner, paper manufacturer, rope and twine maker,dental technician, barber, hairdresser, physician,apparel manufacturer, and plumber.Phenacetin: Phenacetin is a pain medication that is no longer available in the United States, although itis still available in other countries. Large doses havebeen shown to increase the likelihood of developingbladder cancer.Pelvic radiation: Pelvic radiation increases the risk of developing bladder cancer. Women who haveundergone radiation therapy for uterine cancer or ovarian cancer in the past have a twofold to four-fold higher risk of dev eloping bladder cancer. The increased risk is most apparent among women whoreceived radiation doses between 30 and 60 Gy.The risk of bladder cancer increases even more ifchemotherapy was combined with the radiation.Similarly, men who have had radiation therapy forprostate cancer also have an elevated risk of bladdercancer. In those males who develop bladder cancerafter external beam radiation therapy for prostate 16100 QUESTIONS & ANSWERS ABOUT BLADDER CANCER Radiation therapy The use of high-energy radiation todestroy cancer cells;also called radiother-apy or irradiation.95870_PT01_FINAL.QXP 7/2/10 1:03 PM Page 16cancer, the cancers occurred 5.5 years, on average,after the radiation therapy.Chemotherapy and immunosuppression: Chemotherapy with the drug cyclophosphamide (cytoxan) is asso- ciated with up to a ninefold increased risk ofdeveloping bladder cancer. These cancers tend to bemore aggressive as a group. The use of themedication MESNA at the time of cyclophos- phamide administration helps protect the bladderfrom irritation and decreases the risk of developingbladder cancer. A similar chemotherapy agent, ifos-famide (Ifex) is also associated with increased riskof developing bladder cancer. Also, patients who havehad a kidney transplant or other organ transplantsand are on immunosuppression (steroids and othermedications) are known to have a higher risk forbladder cancer.Dehydration: Individuals who typically take in very little fluids are at increased risk of developing bladdercancer. Minimizing fluid intake causes the urine tobecome more concentrated and increases theamount of time between voiding. Holding concen-trated urine for longer periods of time likely plays arole in this increased risk.Arsenic: Arsenic in drinking water is associated with an increased risk of developing bladder cancer.Bladder augmentation: Individuals who undergo bladder augm entation, a surgical procedure whereby the bladder is made larger by attaching a patch ofintestine—small intestine or large intestine, rarely thestomach—are at increased risk for developing bladdercancer. The incidence of developing cancer per decadefollowing augmentation surgery is 1.5% for ileal (smallintestine)/colonic and 2.8% for gastric (stomach) 17100 QUESTIONS & ANSWERS ABOUT BLADDER CANCER Cyclophosphamide (cytoxan) A form of chemother-apy that is associatedwith an increased riskof bladder cancer dueto its toxic effects onthe bladder. MESNA An adjuvant in cancerchemotherapyinvolving cyclophos-phamide (cytoxan)and ifosfamide. Ithelps protect the kid-neys and bladderfrom the toxic effectsof these drugs.95870_PT01_FINAL.QXP 7/2/10 1:03 PM Page 17augmentations. Patients with ileal or colonic bladderaugmentations for congenital bladder abnormalitieshave a 7–8 fold risk, and gastric (stomach) augmentshave a 14–15 fold increased risk of developing bladdercancer compared to the general population. It is rec-ommended that, given the increased risk, individualsundergo routine surveillance starting approximately10 years after the augmentation surgery. 11. Are there dietary changes I could makethat can reduce my risk of bladder cancer? The risk of developing bladder cancer appears to corre-late with fat and cholesterol intake. Some studies havesuggested that eating a low-fat, low-cholesterol dietthat is high in fruits and vegetables may decrease yourrisk of developing bladder cancer.A recent study from Japan showed a decreased risk ofbladder cancer in patients who had diets that werehigh in green vegetables or carrots. Those who ate fiveor more servings per week were half as likely todevelop bladder cancer, as were those who ate one tothree servings per month.Soy protein and garlic intake may also decrease therisk. Garlic has been shown to have a direct toxic effecton bladder cancer cells grown in a culture dish in thelaboratory. This effect may be due to stimulating thebody’s natural defenses to kill cancerous cells.Some vitamins have also been found to have anticancereffects, although little information is specifically relatedto their effects on bladder cancer ( Table 1). In a recent study of almost a million adults, those whowere cigarette smokers and regularly took vitamin E 18100 QUESTIONS & ANSWERS ABOUT BLADDER CANCER The risk ofdevelopingbladder cancerappears tocorrelate withfat and choles- terol intake.95870_PT01_FINAL.QXP 7/2/10 1:03 PM Page 18