Bladder Cancer

Definition/diagnostic criteria Bladder cancer is a malignancy arising from the urothelial lining of the bladder. The most common subtype is urothelial carcinoma (previously termed transitional cell carcinoma), accounting for approximately 90% of cases in the UK. Diagnostic criteria include histological confirmation, typically following a cystoscopy and biopsy.

Epidemiology The incidence is higher in males compared with females and increases significantly with age, predominantly affecting those over 60 years. Known risk factors include smoking, occupational exposure to certain chemicals, and chronic bladder inflammation (Cancer Research UK, 2021).

Diagnosis
Clinical features: Symptoms are often non-specific but can include painless haematuria (either visible or non visible), dysuria, urinary frequency and urgency.

NICE cancer referral guidance suggests referring people using a suspected cancer pathway for bladder cancer if they are:

• aged ≥45 and have unexplained visible haematuria without urinary tract infection, or visible haematuria that persists or recurs after successful treatment of urinary tract infection
• aged ≥60 and have unexplained non‑visible haematuria and either dysuria or a raised white cell count on a blood test

NICE also suggests that non-urgent referral should be considered to exclude bladder cancer in people aged ≥60 with recurrent or persistent unexplained urinary tract infection.

Investigations:

• Initial assessment typically involves urine cytology, ultrasound of the urinary tract and cystoscopy.
• During cystoscopy, suspicious lesions are biopsied for histopathological examination.
• Urinary tract imaging, such as CT urogram, is important for staging and assessing for upper tract involvement.

Treatment Treatment depends on the stage and grade of the cancer.

• Non-muscle invasive bladder cancer (NMIBC): Treatment typically involves transurethral resection of bladder tumour (TURBT), often followed by intravesical chemotherapy or immunotherapy to reduce recurrence risk. Surveillance cystoscopy is a key component of follow-up.
• Muscle-invasive bladder cancer (MIBC): Management may involve radical cystectomy with urinary diversion, although bladder-sparing approaches like radiotherapy combined with chemotherapy are also options. Neoadjuvant chemotherapy is often considered prior to surgery.
• Metastatic disease: Systemic chemotherapy is the mainstay of treatment.

Prognosis Prognosis varies with the stage and grade of the tumour at diagnosis. NMIBC generally has a good prognosis but with a high risk of recurrence. MIBC and metastatic bladder cancer have a poorer prognosis. The five-year survival rate for all stages combined is approximately 53%.