Bladder Cancer in Men Symptoms and Diagnosis
When it comes to genitourinary cancers in men, most people put their attention toward prostate cancer or testicular cancer. What many people fail to realize is that another form—bladder cancer—is the fourth leading malignancy in men, far outpacing testicular cancer by a rate of six to one. The symptoms of bladder cancer are often mistaken for other diseases and may include hematuria (blood in the urine) and urinary frequency. If diagnosed early, success rates for treatment—which may involve surgery, chemotherapy, or immunotherapy—are high. With that being said, recurrence is common.
As many as 53,000 American men are diagnosed with bladder cancer each year, while over 12,000 are expected to die as a result of the malignancy.
By far the most common bladder cancer in the United States is transitional cell carcinoma (TCC), also known as urothelial carcinoma. This type is limited to the innermost lining of the bladder (known as the transitional epithelium). Because the transitional epithelium is only a few cells thick, catching cancer at this early stage—when it is considered non-invasive—translates to high rates of treatment success.
While 70 percent of bladder cancers are confined to the transitional epithelium, others will penetrate deeper into the bladder wall. Those that involve the underlying layer of cells, called the lamina propria, are referred to as non-muscle invasive carcinoma. Those that penetrate even deeper into the muscles of the bladder wall are classified as invasive carcinomas.
Once cancer spreads (metastasizes) beyond the confines of the bladder—most of often to lymph nodes, bones, lungs, liver, or peritoneum—it becomes more difficult to treat and control.
In addition to TCC, other, less common types of bladder cancer include adenocarcinomas, small cell carcinomas, and sarcomas. These types are considered uncommon and account for less than one percent of all U.S. cases.
Bladder cancer is often painless. The most significant sign of malignancy is urinary bleeding, either overt (known as gross hematuria) or detected with blood or imaging tests (microscopic hematuria). The bleeding may be consistent or intermittent. While blood in urine may be distressing, it is neither diagnostic of cancer nor predictive of the severity of a malignancy.
The signs and symptoms of bladder cancer can vary based on the size and location of the tumor as well as the stage of the disease. In addition to bleeding, other symptoms may include:
- A persistent urge to urinate (urinary urgency)
- Frequent urination (urinary frequency)
- Back or abdominal pain
- Loss of appetite
- Unexplained weight loss
Like any cancer, bladder cancer is due to mutated cells that proliferate and form a tumor—in this case, in the bladder. For reasons not entirely understood, bladder cancer affects men four times more than women, with the vast majority of cases occurring in men over 50. The disease is more common in white than black men.
The exact cause of one’s bladder cancer is not always certain, but there are contributing factors that doctors can point to.
Beyond the male gender, race, and older age, cigarette smoking remains the most significant risk factor for bladder cancer. Because many of the carcinogens found in cigarettes are expelled from the body in urine, the persistent exposure to these compounds can double your risk of bladder cancer compared to non-smokers. Moreover, the risk increases in relation to the number of cigarettes you smoke.
Other factors may include:
- Prolonged exposure to industrial toxins (although the incidence has decreased with improved workplace safety regulations
- Prolonged use of Cytoxan (cyclophosphamide) chemotherapy
- Radiation therapy for prostate cancer
- Chronic urinary tract infections (UTIs)
- Schistosomiasis, a parasitic infection common in the tropics
Certain genetic mutations (particularly the FGFR3, RB1, HRAS, TP53, and TSC1 mutations) may further predispose you to bladder cancer.
Family history may also play a role. Rare inheritable genetic disorders like Lynch syndrome (associated with colorectal cancer), Cowden disease (linked to thyroid and breast cancer), and retinoblastoma (an eye cancer) may potentially increase your risk of bladder cancer.
The diagnosis of bladder cancer is often complicated by the fact that it shares many of the same symptoms of other, more common genitourinary conditions, including kidney stones and UTIs.
To this end, the diagnosis relies heavily on the exclusion of all other causes before more invasive investigations begin. This may include a digital rectal exam and prostate-specific antigen (PSA) test to rule out prostate problems. Imaging tests such as X-rays and computed tomography (CT) may be used to exclude kidney stones, bladder stones, and urinary tract disorders.
While urinary cytology (the microscopic evaluation of urine to check for cancer cells) may provide evidence of cancer, the test is often inaccurate if the tumor is small and non-invasive.
The same applies to newer options called the bladder tumor antigen (BTA) and nuclear matrix protein 22 (NMP) tests, both of which are more likely to detect larger, more advanced tumors. As such, these tests are more useful in monitoring a diagnosed malignancy than establishing the initial diagnosis.
The gold standard for diagnosis of bladder cancer is cystoscopy. The direct viewing technique is performed under local anesthesia to numb the urethra (the tube through which urine exits the body).
The cystoscope is comprised of either a 2.9-millimeter or 4.0-millimeter tube that is inserted into the urethra to get an up-close view of the internal structure of the bladder. Tiny instruments can also be fed through the scope to obtain tissue samples for evaluation in the lab.
While cystoscopy can offer definitive evidence of bladder cancer, additional tests such as a bone scan, liver function tests, and CT scans of the chest, pelvis, and abdomen may be used to establish if and how far the cancer has spread.
Based on a review of the test result, a specialist known as a urologic oncologist will stage the cancer. Cancer staging is used to determine the appropriate course of treatment depending on the characteristics of the tumor. It can also help predict the likely outcome (prognosis) of the disease.
The staging is classified based on the type and location of the tumor as follows:
- T0: No evidence of cancer
- Ta: A non-invasive papillary (finger-like) tumor
- Tis: A non-invasive flat carcinoma (carcinoma in situ)
- T1: Infiltration of the lamina propria
- T2A: Infiltration of the inner muscle
- T2b: Infiltration of the deep muscle
- T3: Extending beyond the bladder wall
- T4a: Involving the prostate gland or seminal vesicles
- T4b: Involving the pelvic wall or abdominal wall
If the lymph nodes are involved, “N+” is tagged onto the end of the tumor stage (for example, T3N+). If cancer has metastasized to the lymph nodes and distant organs, “N+M1” is tagged to the end of the tumor stage.
The treatment of bladder cancer varies by the stage of the disease and whether other organs have been affected.
Ta, Tis, and T1 tumors
The mainstay of treatment of Ta, Tis, and T1 cancers is the surgical removal of visible tumors. The procedure, known as transurethral resection of the bladder tumor (TURBT), is performed under general or regional anesthesia using a specially equipped cystoscope. The urologist may also place you on a course of chemotherapy to kill all remaining cancer cells. Mitomycin C is a commonly used chemotherapeutic agent.
If the cancer is likely to recur (such as can occur with stage Tis tumors), immunotherapy may be used to help boost the body’s tumor-fighting cells. The Bacillus Calmette-Guerin (BCG) vaccine, developed in 1921 to fight tuberculosis, has proven effective in preventing cancer recurrence when injected directly into the bladder.
T2 and T3 tumors
More aggressive T2 and T3 tumors may require more than just the removal of visible tumors. By this stage of the disease, many urologists will recommend a radical cystectomy, in which the entire bladder is removed along with the adjacent lymph nodes, the prostate gland, and the seminal vesicles. Supplemental chemotherapy is often recommended.
While a radical cystectomy is undoubtedly life-altering, newer reconstructive techniques have lessened the functional impact of the procedure. Today, a skilled urologist can create a substitute bladder using part of the intestinal tract and redirect the urine flow so that you can urinate as before. On the downside, erectile dysfunction is more the rule than the exception.
Less aggressive T2 tumors may sometimes be treated with a partial cystectomy. This involves the removal of the affected area of the bladder and does not require reconstructive surgery. Partial cystectomy is almost never used in people with stage T3 cancer.
Given that T4 tumors are characterized by the spread of cancer beyond the bladder, a radical cystectomy can only do so much to control the disease.
If cancer has yet to affect distant organs, chemotherapy (with or without radiation) will usually be the first-line option. If chemo is able to shrink the tumor, cystectomy may be considered. If the chemotherapy is intolerable, radiation may be used in combination with immunotherapeutic drugs, such as atezolizumab or pembrolizumab.
Because treatment is unlikely to cure a T4 tumor, much of the focus is placed on slowing the progression of the disease and maintaining the best quality of life possible.
The survival rate following bladder cancer treatment can vary based on the stage of the disease at the time of diagnosis. The rates are described by the percentage of people who have survived for five years following the completion of therapy.
Statistically speaking, the five-year survival rate is as follows:
- Stage 0: 98 percent
- Stage 1: 88 percent
- Stage 2: 63 percent
- Stage 3: 46 percent
- Stage 4: 15 percent
Note, though, that this does not mean that you are only expected to live for five years. The figures are simply meant to gauge the effectiveness of treatment. Many people treated for bladder cancer will go on to live long, healthy lives well in excess of 15 and even 20 years.
Even if you have been successfully treated for bladder cancer, it often takes time to readjust to what lies ahead. Recurrence of the disease is common, and you will likely need to change your lifestyle to stay one step ahead of the disease.
According to research from the David Geffen School of Medicine in Los Angeles, 39.1 percent of people treated for bladder cancer will have a recurrence without disease progression, while 33 percent will experience a recurrence with disease progression. To this end, a routine evaluation may be needed every three to six months depending on the nature and severity of your disease. This may involve routine cystoscopy, urinary cytology, and other blood, urine, or imaging tests.
You also need to take the extra steps to decrease your personal risk of relapse. Among the considerations:
Quitting cigarettes is considered a must. Even if you have smoked heavily in the past, studies suggest that your risk of recurrence may be entirely mitigated if you remain smoke-free for 10 years.
Low-fat diets are believed to be beneficial, both in preventing bladder cancer and avoiding recurrence. Red meat and fried foods should be avoided, both of which are associated with a twofold increase in risk.
Antioxidant-rich foods may also help reduce cancer risk, including those that contain quercetin (cranberries, broccoli), lycopene (tomatoes, carrots, red cabbage), vitamin E (almonds, sunflower seeds), or epigallocatechin gallate (green tea, apples, dark chocolate).
Increased fluid intake may also decrease your risk. A 10-year retrospective study concluded that men who drank two quarts of water per day were 49 percent less likely to get bladder cancer compared to those who drank less a quart per day.
While highly treatable, bladder cancer remains a scary prospect for men given the high rate of recurrence and the need for surgical intervention.
With that being said, early diagnosis is associated with less invasive interventions. Most TURBT surgeries, in fact, require no more than a couple of days in the hospital and a couple of weeks of recovery time. By contrast, delayed diagnoses place you at increased risk of more invasive—and potentially life-changing—medical procedures.
It is important, therefore, to pay attention to your genitourinary health and to not ignore symptoms that either persist or recur. In the end, there is no such thing a “less worrisome” amount of blood in urine. Even milder signs such as the urinary frequency should be considered a red flag if they persist for more than a few days.
If your doctor is unable to find the source of your urinary symptoms, ask for a referral to a board-certified urologist who can run a more extensive battery of tests. Whatever you do, don’t let embarrassment or discomfort stand in your way of getting the diagnosis you need.
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