Bladder cancer

Disease Description (Causes and Symptoms)

• Definition summary: Bladder cancer is a malignant neoplasm arising from the epithelium inside the bladder, primarily the transitional epithelium. It occurs mainly in people in their 60s–70s and is 3–4 times more common in men than in women.
• Pathophysiology: Most cases (approximately 90%) are transitional/urothelial carcinoma, while a minority are squamous cell carcinoma (6–8%) or adenocarcinoma (approximately 2%). It begins as superficial (non-muscle-invasive) disease and progresses to invasive disease when it invades the muscular layer. The depth of tumor invasion, presence of lymph node metastasis, and presence of distant metastasis determine the stage and prognosis.
• Main causes/risk factors:
  • Smoking (2–4 times higher risk than in nonsmokers)
  • Occupational/environmental exposure to carcinogens (such as arylamines and industrial chemicals)
  • Radiation exposure and some anticancer drugs (e.g., cyclophosphamide)
  • Chronic urinary tract infections and bladder stones
  • Other reported associated factors: analgesics, coffee, artificial sweeteners, etc. (the association varies among studies)
• Main symptoms:
  • Hematuria (observed as the first symptom in 80–90% of cases; either gross or microscopic)
  • Dysuria (pain during urination), urinary frequency, and urgency
  • Flank pain or lower-extremity edema caused by ureteral obstruction
  • With progression, a palpable pelvic mass, weight loss, and systemic symptoms

Treatment Methods

• Principles of diagnostic treatment:
  • Cystoscopy and biopsy of the lesion or transurethral resection of bladder tumor (TURBT) are the basis of diagnosis and initial treatment.
  • Urine cytology, CT (to evaluate the ureters and renal pelvis), IVP, or retrograde pyelography may be performed for staging.
• Superficial (non-muscle-invasive) bladder cancer:
  • Basic treatment: Removal of the lesion and biopsy through transurethral resection of bladder tumor (TURBT).
  • Adjuvant/maintenance treatment: Intravesical therapy — BCG (immunotherapy), intravesical anticancer drugs (e.g., mitomycin C), etc.; the choice depends on the tumor’s pathological findings (grade), size, number, and recurrence history.
  • For recurrent or high-risk lesions, repeat resection or bladder removal may be considered.
• Invasive (muscle-invasive) bladder cancer:
  • Radical cystectomy and pelvic lymph node dissection are standard treatments, particularly for muscle-invasive disease.
  • Neoadjuvant or adjuvant systemic chemotherapy (cisplatin-based) often provides a survival benefit.
  • A bladder-preservation strategy (combined radiation therapy and chemotherapy instead of surgery) may be considered in selected situations.
• Metastatic (distantly metastatic) bladder cancer:
  • Cisplatin-based systemic chemotherapy (e.g., cisplatin + gemcitabine) is the standard first-line treatment.
  • Immune checkpoint inhibitors (PD-1/PD-L1 inhibitors: pembrolizumab, atezolizumab, etc.) may be used in patients with disease progression or those who are ineligible for cisplatin.
• Symptom relief and lifestyle management:
  • Pain control, management of urinary retention or ureteral obstruction (stents, nephrostomy drainage, etc.), treatment of infections, and rehabilitation to preserve nutrition and function.
  • Smoking cessation, avoidance of carcinogen exposure, and adequate fluid intake are recommended.
• Follow-up:
  • Because superficial bladder cancer has a high recurrence rate, regular cystoscopic examinations (generally every 3 months, etc.) are performed over an extended period of several years.
• Treatment considerations:
  • The morbidity and mortality risks of major surgery such as bladder removal, as well as postoperative changes in urination and sexual function, should be discussed in advance.

Checklist Before an Outpatient Visit (Including Preparation Items and Example Questions)

• Items/documents to prepare:
  • A list of all medications currently being taken (including prescription drugs, OTC drugs, and supplements)
  • Previous test results (cystoscopy findings, biopsy results, and CT/ultrasound/IVP reports)
  • Urinalysis and urine culture results
  • A record of recent symptom changes (date, frequency, and pattern of hematuria; pain; urinary symptoms, etc.)
  • Information on smoking history and occupational history (history of chemical exposure)
• Points to check before the outpatient visit:
  • Whether bladder removal or intravesical treatment (such as BCG) has been received previously
  • Kidney function (creatinine) level and whether contrast media will be used (for CT)
  • History of allergies (medications, contrast media, etc.)
• Key documents to show the doctor:
  • Biopsy (pathology) report, imaging reports, and recent blood test results

General Examples of Questions to Ask the Doctor

• "What are the exact stage (T/N/M) and grade of my cancer?"
• "What treatment options are recommended, and what are the advantages, disadvantages, and side effects of each option?"
• "What complications can be expected with surgery (bladder removal), and what will the recovery process be like?"
• "What is the risk of recurrence after treatment, and what is the follow-up examination schedule?"
• "How will treatment affect sexual function or urinary function?"

Examples of Disease-Specific Questions

• "According to the pathology report, is my tumor superficial? What is the extent of muscle-layer invasion (average invasion depth) and the grade?"
• "Is BCG (intravesical immunotherapy) appropriate in my case? If BCG fails, what are the next options?"
• "I was told there is ureteral obstruction or an abnormality in the renal pelvis — what measures are needed to preserve kidney function?"

Additional Reference (Summary)

• Superficial bladder cancer: Accounts for approximately 70–80% of all cases and has a high recurrence rate (approximately 60–70%), making regular follow-up essential; 20–30% may progress to invasive disease.
• Key diagnostic tests: Urine cytology, cystoscopy and TURBT, and CT/assessment of the ureters and renal pelvis (IVP/retrograde contrast studies, etc.).
• Main preventive measures: Smoking cessation, minimizing occupational/environmental exposure to carcinogens, and treatment of chronic urinary tract infections and stones.