Where there is smoke there may be a fire - be serious about bladder cancer

Bladder cancer is a term that refers to malignant tumours that affect the inner lining of the bladder wall. These tumours are usually detected when the person notices blood in their urine (painless visible haematuria) or if blood is detected in a dipstick (asymptomatic non-visible haematuria) as part of a medical investigation. The most common form of bladder cancer is called transitional cell carcinoma (>90%), other forms of bladder cancer include: squamous cell carcinoma (1-7%), adenocarcinoma (2%) and rarer types (phaeochromocytoma, melanoma, lymphoma and sarcoma).

Around 10,100 people are diagnosed with bladder cancer each year in the UK. It is the 10^th most common cancer (apart from skin cancer) and the 8^th most common cancer in men. It seems to affect more men than women, possibly because more men have smoked or have been exposed to chemicals at work in recent decades. There does not seem to be a hereditary genetic pattern associated with bladder cancer.

Apart from smoking, which is the major cause of bladder cancer, occupational exposure to certain chemicals, environmental carcinogens, chronic bladder inflammation, certain drugs and radiotherapy are also recognised risk factors for bladder cancer.

The following occupations are known to be associated with transitional cell carcinoma (TCC):

• Rubber manufacturing eg tyres or electric cables
• Paint and dye industries
• Fine chemical manufacturing eg auramine
• Gas and tar manufacturing
• Iron and aluminium processing
• Hairdressers
• Leather workers
• Plumbers
• Painters
• Drivers exposed to diesel exhaust fumes

Primary transitional cell carcinoma (TCC) is considered clinically as superficial or muscle-invasive (deep). 70% of tumours are papillary (a bit like a see anemone or cauliflower) and usually low grade and superficial. 10% of patient subsequently develop deeper muscle-invasive and more aggressive disease. 10% have mixed papillary and solid morphology (histological appearance – usually high grade), whereas 10% of TCC is flat carcinoma in situ (CIS).

I would strongly recommend that any adult that notices blood in their urine sees a doctor. Although there are many other potential causes for visible (around one in five may have bladder cancer) and non-visible blood (around one in 12 may have bladder cancer) in their urine, I would still recommend seeing a healthcare professional.

As a Urologist, I will investigate for bladder cancer with imaging of the upper urinary tracts (ultrasound or CT scan) and with direct visualisation (performing a cystoscopy – telescopic bladder examination carried out under local or general anaesthetic).

If bladder cancer is found we would usually treat it with an endoscopic resection under anaesthetic (with a telescope via the urethra, making use of diathermy). In most cases this is an efficient way of successfully treating the bladder cancer. Higher grade cancers tend to return, in such cases we use intravesical installations (fluid inserted into the bladder with a catheter) of medication that prevents this. In rarer cases, more radical surgery or radiotherapy is recommended.

It is important to keep an eye on patients with previous bladder cancer to ensure it does not return with regular check-ups for some years after their first diagnosis.

I would encourage anyone reading this article to be serious about cancer and to seek medical advice if you experience any blood in your urine or have unexplained urinary symptoms (eg pain in the absence of infection) especially if you might fall in any of the risk categories discussed. The earlier the better. Just ask.

For more information please see the BAUS (The British Association of Urological Surgeons) website (www.baus.org.uk) where it explains about blood in the urine and the different treatments for bladder cancer. There is a video on an endoscopic resection of a bladder tumour (TURBT) for anyone interested.

 Written by Mr Jacques Roux.