Bladder Cancer: Symptoms, Diagnosis and Current Treatment Options

What is bladder cancer?

The great majority of bladder cancers are urothelial carcinomas. Tumours are divided into two main groups: non-muscle-invasive tumours that stay limited to the inner surface of the bladder, and muscle-invasive tumours that reach the muscle layer in the bladder wall. This distinction determines both the choice of treatment and the frequency of follow-up [1][4].

What causes bladder cancer? Risk factors

Smoking is the most important risk factor for bladder cancer; the carcinogens in tobacco pass into the blood, are filtered by the kidneys, accumulate in the urine and come into contact with the bladder wall. Workplace exposure to dyes, metals or petroleum products, arsenic in drinking water, previous radiotherapy to the pelvis or treatment with certain drugs such as cyclophosphamide, and a family history of bladder cancer also increase the risk [2].

How common is bladder cancer?

Bladder cancer is more common in men than in women. It can occur at any age; however, the risk rises markedly with age [2].

What are the symptoms of bladder cancer?

• Blood in the urine (it can range from rust-coloured to bright red; sometimes it is detected only on a urine test)
• Frequent urination, getting up at night to urinate
• Pain or burning when passing urine
• A feeling of needing to urinate even when the bladder is not full

Blood in the urine can be intermittent; its being seen once and then disappearing does not mean that evaluation is not needed [3].

How is bladder cancer diagnosed?

The basis of diagnosis is cystoscopy, in which the inside of the bladder is examined with a thin camera. The suspicious area is removed by transurethral resection (TURBT) and sent for pathology; this determines the type and grade of the tumour and whether it has reached the muscle layer. CT urography and thoracic CT are used to assess the upper urinary tract and spread; urine cytology helps the diagnosis [4].

Molecular tests

In advanced disease, testing tumour tissue for gene alterations such as FGFR3 with NGS can reveal targeted treatment options [1][4].

How is bladder cancer treated?

Treatment is planned according to stage and risk group. Assoc. Prof. Dr. Ali Oğul’s approach is to evaluate patient files in a multidisciplinary tumour board with specialists in urology, radiation oncology, radiology and pathology.

Non-muscle-invasive disease

After TURBT, depending on the risk of recurrence, BCG (immune therapy) or chemotherapy drugs such as gemcitabine and mitomycin are instilled into the bladder. There are also newly developed intravesical immunotherapy and gene therapy options [1].

Muscle-invasive disease

In suitable patients, chemotherapy containing cisplatin before surgery followed by radical cystectomy is the standard approach. Adding the immunotherapy drug durvalumab to the chemotherapy before surgery and continuing it after surgery significantly prolonged event-free survival and overall survival [5]. In selected patients, bladder-preserving chemoradiotherapy can also be considered [4].

Metastatic disease

In the first line, the combination of the antibody-drug conjugate enfortumab vedotin with pembrolizumab significantly prolonged overall survival compared with platinum-containing chemotherapy [6]. In tumours with an FGFR3 alteration erdafitinib, avelumab maintenance after platinum chemotherapy and other immunotherapies are among the options, depending on the patient’s condition [1][4].

Latest regulatory updates for this cancer type: Bladder Cancer: Latest Developments

Side effects and follow-up during treatment

Intravesical BCG can cause burning on urination, frequent urination and a mild fever. With enfortumab vedotin, skin rash, numbness in the hands and feet and raised blood sugar may occur; with immunotherapy, immune-related side effects. Because recurrence is common in non-muscle-invasive bladder cancer, regular cystoscopy checks are necessary [4].

Can bladder cancer be prevented?

The most important measure is never starting to smoke or quitting. Protective measures against chemical exposure in the workplace and safe drinking water can also reduce the risk [2].