Bladder cancer

Bladder cancer starts in the lining — the layer that covers the bladder from the inside and sits in urine all the time. That is exactly why substances that end up in urine matter so much here: they spend hours in contact with that wall. It appears mostly after sixty and more often in men. In most people the tumour has not yet grown into the muscle layer by the time it is found. And almost always the first announcement comes from a single sign: blood in the urine.

Blood in the urine that does not hurt

Urine can turn pink, the colour of meat washings, or as dark as tea. Sometimes there is enough blood for clots to appear. The telling feature is the absence of pain: with a stone or an infection blood comes with burning; with a tumour, as a rule, nothing bothers you at all.

That is where the main trap lies. The blood shows up once, the next day the urine is clear again, and the person decides it was nothing. A few months pass, the episode repeats, and time has been lost. Blood disappearing does not mean the cause has disappeared. One visible episode is enough to warrant investigation, particularly after forty.

Blood can also be invisible, picked up in a routine urine test done for something else. That finding is not left alone either.

The other signs draw less attention and are easily mistaken for familiar things:

• needing to pass urine often, including at night, and the feeling that you have to go right now;
• burning or discomfort on passing urine with no sign of infection in the tests;
• "cystitis" that keeps coming back or does not respond to antibiotics — in a man this is a particularly weighty reason to look further, because ordinary cystitis is uncommon in men;
• a dull ache low in the abdomen, in the lower back or between the legs;
• at a late stage, weight loss for no reason, weakness, bone pain, swelling of one leg.

None of these signs on its own means cancer: far more often the answer is an infection, a stone or an enlarged prostate. But the one who should sort it out is a doctor.

What raises the risk

The leading cause is smoking. Carcinogens from tobacco smoke pass into the blood, the kidneys filter them out, and they end up concentrated in urine, in prolonged contact with the bladder wall. A smoker's risk is several times higher, and after stopping it falls slowly, over years, but it does fall.

The second factor in importance is occupational. The danger comes from aromatic amines and related compounds, used in making dyes, rubber and leather, in painting and decorating, printing, oil refining, and in hairdressing with constant handling of colourants. What is peculiar about this risk is the gap of twenty to thirty years between exposure and illness. If you worked in such a trade long ago, tell the doctor — the question will not occur to them on their own.

Less often the following play a part:

• a urinary catheter left in place for a long time, and repeated urinary infections;
• schistosomiasis, a parasitic disease of fresh water in Africa and the Middle East; in Europe it turns up in people who lived or swam there, and it gives rise to a distinct type of tumour;
• past radiotherapy to the pelvis, or treatment with certain chemotherapy medicines;
• bladder cancer in close relatives, and the inherited Lynch syndrome;
• arsenic in drinking water from unchecked sources.

What you can do yourself: stop smoking, the measure with the most weight behind it; use protection in hazardous work and do not skip occupational health checks; drink enough water and do not hold on for hours.

How the cause is looked for

The work-up begins with a urine test and an ultrasound scan. One point matters here: a normal scan does not rule a tumour out. Small and flat lesions are not visible on it, and "the scan was clear" alongside visible blood in the urine is no reason to relax.

The decisive test is cystoscopy: a thin flexible instrument with a camera is passed along the urethra and the bladder is inspected from within. Anaesthetic gel goes in first; the procedure is unpleasant but usually not painful and takes a few minutes. If a suspicious area is seen, a piece of tissue is taken.

The picture is completed by examining urine cells under the microscope and by a contrast scan showing the kidneys, the ureters and the neighbouring organs. The doctor may also examine you through the back passage or the vagina — that is part of a standard assessment rather than anything exceptional, and you may ask for a doctor of your own sex and for a third person to be present in the room.

There is no need to feel awkward talking about urine: for a urologist it is the daily subject, and a visit put off out of embarrassment is time lost.

Why this is not one single disease

Once the suspicious area has been removed, the pathologist looks at how deeply the tumour has gone into the wall. Everything that follows depends on that answer.

In most patients the tumour stays within the lining and does not reach the muscle layer. Such forms do not usually threaten life, but they tend to come back, so the bladder has to be watched for years. If the tumour has grown into the muscle, the disease behaves far more aggressively and the treatment matches that. The grade of the cells is judged separately: even a superficial tumour, if it is high grade, calls for an active approach.

How it is treated

A tumour that has not reached the muscle is removed through the urethra, with no cuts. After that, to lower the chance of it returning, a medicine is put into the bladder through a catheter — either a chemotherapy drug or BCG vaccine, which prompts the immune system to attack any remaining cells. The course stretches over months and is worth completing, because it is what keeps the disease in check.

Where the muscle is involved there are two main routes: removing the bladder and creating a new way for urine to leave the body, or combining radiotherapy with chemotherapy, which allows the bladder to be kept. Platinum-based chemotherapy is often given before surgery, as it improves the odds. The choice depends on where the tumour sits, on age, on other illnesses and on what matters most to the person; it is a decision made together with the doctors, not on the patient's behalf.

In advanced disease, chemotherapy, immunotherapy and targeted medicines are used. Even where full cure is not possible, treatment can slow the tumour down and ease symptoms, and the palliative care team comes in not "at the end" but whenever comfort needs improving.

Why follow-up does not end

The distinctive thing about this tumour is how often it comes back. That is why regular cystoscopies are scheduled after treatment: every few months at first, then further apart. They are not worth skipping even when you feel perfectly well, because a returning tumour again produces no sensation at its early stage beyond that same blood in the urine.

Stopping smoking after the diagnosis lowers the chance of recurrence. Between appointments, keep an eye on the colour of your urine and report any episode of blood without waiting for the scheduled date.

Online consultation

An online appointment earns its place at the point where the warning sign has already appeared and it is unclear what to do about it. The doctor goes through what the urine looked like and how many times it has happened, sets that against age, years of smoking and past work, explains which tests are ordered in this situation and why an ultrasound alone is not enough, helps read results and reports you already have, and advises what to bring to the urologist. If the account points to a need for urgent face-to-face care — retention of urine, say, or heavy bleeding with clots — the doctor will say so plainly.

This material is for information only and does not replace medical advice.