Joseph R. Anticaglia, MD
Medical Advisory Board
In January of 2023, the American Cancer Society estimated there’ll be about 82,290 new cases of bladder cancer, and about 16,710 deaths from bladder cancer in the United States. Men are about three times more likely to be stricken by bladder cancer (BLCA) than women. A previous article discussed the symptoms, and diagnosis of bladder cancer. This article will discuss how grading and staging of the tumor predict your survival, and treatment.
Grading and Staging of cancer are parts of the diagnosis, and treatment process for cancers. The grade (type) of cancer describes how normal, and abnormal cancer cells look under the microscope. The more normal the cells look (low grade), the less aggressive the cancer. In contrast, the more abnormal the cells look under the microscope (high grade), the more aggressive the cancer, and it’s more likely to grow and spread.
Nonmuscle invasive bladder cancer is a low grade cancer that involves only the urothelial, (also called transitional) cell layer of the bladder. Its cancer cells do not invade the muscle layer, and at times, grow in the opposite direction of the muscle layer into the interior of the bladder resembling a cauliflower. It makes up the majority of newly diagnosed bladder cancers, and is rarely life-threatening.
Muscle invasive bladder cancer is a high grade cancer that has tumor cells in the muscle layer of the bladder. It’s a life threatening type of cancer that can grow, and invade other parts of the body. It requires aggressive treatment.
Staging refers to the size of the cancer, and whether it has spread to the lymph nodes, or other parts of the body. MRI, CT scan, and PET scan are useful in staging cancer. Treatment decisions for cancer patients, to a great extent, depend on the staging of the cancer.
Staging bladder cancers tells doctors how much cancer is in a person’s body. It lets him/her know if the cancer is localized to the bladder, or spread beyond the wall of the bladder to the lymph nodes, or other parts of the body.
Metastatic bladder cancer means the cancer extends beyond the bladder involving at least one other organ. For example, the bladder cancer has spread, metastasized, to the lungs. Doctors use staging numbers and letters to assist them in diagnosing and treating cancer patients. Refer to glossary for more detailed description of the staging process.
The type of treatment for bladder cancer depends on the grade of cancer, the stage of cancer as well as the persons overall health. It may include surgery to remove the tumor, chemotherapy to kill cancer cells, immunotherapy to boost the body’s immune system, and targeted therapy to target specific genes, proteins that are involved in the growth of cancer cells, or combinations of the above.
Nonmuscle Invasive Cancer (Low Grade)
A transurethral resection of a bladder tumor (TURBT) is usually the initial treatment for nonmuscle invasive bladder carcinoma. The surgeon uses a cystoscope to visualize the bladder cancer. He/she then passes an instrument such as a small wire loop down the cystoscope to remove the tumor from the bladder’s lining, and electric cautery to burn away the remaining cancer cells. These patients require frequent, follow-up care to identify, and treat recurrences,
Patients benefit from intravesical therapy which involves placing medication (chemotherapy, BCG (see glossary)) directly into the bladder to prevent recurrences. It’s used to treat cancer that hasn’t spread beyond the lining (urothelium) of the bladder.
Once the cancer cells have invaded the muscle layer of the bladder, experts recommend — cystectomy. It is the surgical removal of the entire bladder, surrounding tissue, and lymph nodes. These patients benefit most from a team of specialists to manage this high grade tumor that include the family doctor, oncologist, radiologist, surgeon, and social worker.
Smoking causes about half of new bladder cancers. Blood in the urine is the most common symptom of bladder cancer. A biopsy is needed to make a definitive diagnosis of cancer. Nonmuscle invasive carcinoma accounts for about 90% of all bladder cancers, and has the best five year (90%) survival rate. Men get it three times more frequently than women. Early diagnosis and treatment are the keys to survival. Strick follow-up care is necessary to identify recurrent bladder cancer, and reduce the chance of it spreading to other parts of the body. Early diagnosis and treatment are the keys to survival.
Staging of cancer using numbers and letters:
Number staging uses numbers from zero to four to characterize the extent of the bladder tumor in the body, according to the National Health Service (NHS). A simplification of the staging system follows:
Stage 0 the cancer is where it started (in situ), and hasn’t spread.
Stage 1 is a localized, small cancer that hasn’t spread.
Stage 2 is a cancer that has grown, and spread into muscle layer (wall) of the bladder but hasn’t spread beyond the wall of the bladder.
Stage 3 the cancer has spread to the surrounding tissues and lymph nodes
Stage 4 metastatic cancer — the cancer has spread to at least one other body organ.
TNM staging system according to the NHS:
Stages numbered three and four have much poorer outcomes and survival rates compared to earlier bladder cancer stages. Concerning the TNM staging system, the bigger the size of the tumor, with many lymph nodes, which has spread to another part of the body is a bleak survival outlook in most instances. The good news is urothelial carcinoma accounts for about 90% of all bladder cancers, and has the best five year (90%) survival rate.
Hematuria — blood in the urine.
NHGRI — National Human Genome Research Institute from Bethesda, MD
Urothelium is the continuous lining of the urinary tract from the bladder up to the kidney. Urothelial cells, also called transitional cells, are specialized epithelial cells.
Diagram Layers of the Bladder — credit Urological Associates of Piedmont
NHS — National Health Service
BCG Bacillus Calmette-Guerin is a vaccine primarily used against tuberculosis. It has been used as intravesical therapy in patients with nonmuscle invasive bladder cancer. It’s a type of immunotherapy that works through the patient’s own immune system.
On April 3, 2023, the U. S. Food and Drug administration (FDA), approved enfortumab vedotin (Padcev®) plus the immunotherapy drug pembrolizumab (Keytruda®) for people newly diagnosed patients with metastatic urothelial carcinoma.
This article is intended solely as a learning experience. Please consult your physician for diagnostic and treatment options.
