Bladder Cancer Survivorship: Follow-Up Questions

NCI's PDQ summary for health professionals opens its follow-up section with the reason. Bladder cancer tends to recur, even when it is noninvasive at diagnosis. So standard practice is surveillance of the urinary tract after any bladder cancer diagnosis.

Then it says something most summaries leave out. No trials have been conducted to assess whether surveillance affects rates of progression, survival, or quality of life. And clinical trials have not defined an optimal surveillance schedule.

That is worth carrying into a visit. Any interval quoted — every three months, every six — comes from local practice or a specialty guideline, not from a trial PDQ can point to. Asking which guideline a schedule follows is a fair question.

PDQ explains why bladder cancer behaves differently from most solid tumors.

Urothelial carcinomas are thought to reflect a field defect. The idea is that cancer emerges from genetic variants already spread widely. Those variants may cover the whole bladder, or the whole urothelium. The urothelium is the lining of the entire urinary tract.

The consequence is practical. People who have had a bladder tumor removed often develop new tumors later, frequently in different locations from the first one. Less commonly, tumors appear in the upper urinary tract, in the renal pelvises or ureters.

PDQ offers an alternative explanation as well. Cells disrupted during resection may reimplant elsewhere in the urothelium. It notes the evidence for that theory. Tumors are more likely to return downstream than upstream from the original cancer.

Because the field defect is not confined to the bladder, PDQ says upper urinary tract imaging is essential for both staging and surveillance in bladder cancer.

It lists four ways to do it. Ureteroscopy. Retrograde pyelograms during cystoscopy. Intravenous pyelograms. Or CT urograms.

The relationship runs both ways. PDQ says people with an upper urinary tract cancer face a high risk of bladder cancer. They need periodic cystoscopy. They also need surveillance of the upper tract on the other side.

PDQ is blunt on this point, and it answers a question many people ask.

When bladder cancer is suspected, the most useful diagnostic test is cystoscopy. Radiological studies such as CT scans or ultrasound do not have sufficient sensitivity to detect bladder cancers.

PDQ describes how it works in practice. Cystoscopy can be done in a urology clinic. If cancer is seen, the next step usually moves to an operating room. There, an exam under anesthesia and a repeat cystoscopy allow resection or biopsies.

If a high-grade or invasive cancer is found, staging follows. PDQ says that means a CT of the abdomen and pelvis, or a CT urogram. It also means either a chest x-ray or a chest CT. A bone scan is added in two cases. One is a rise in alkaline phosphatase that is not from the liver. The other is symptoms suggesting bone spread.

PDQ states that the most common risk factor for bladder cancer in the United States is cigarette smoking. It estimates smoking causes up to one-half of all bladder cancers. It says smoking raises a person's risk two to four times above baseline.

There is a genetic wrinkle. Some smokers carry less functional forms of an enzyme called N-acetyltransferase-2. PDQ calls them slow acetylators. It says their risk runs higher than other smokers, likely because they detoxify carcinogens less well.

Given the field defect, a bladder already carrying widespread genetic damage keeps meeting the same carcinogens with every cigarette. That is the reason quitting is a surveillance issue and not only a general health one.

PDQ lists jobs with higher bladder cancer rates. Textile dye and rubber tire industries. Painters. Leather workers. Shoemakers. And aluminum, iron, and steel workers.

It names three chemicals linked to bladder cancer. They are beta-naphthylamine, 4-aminobiphenyl, and benzidine. PDQ notes these are now generally banned in Western countries. It adds that many other chemicals still in use are suspected.

Past treatment matters too. PDQ links the chemo drug cyclophosphamide to higher bladder cancer risk. It also lists earlier treatment with cyclophosphamide, ifosfamide, or pelvic radiation for another cancer. Chronic urinary infections appear on the list, as does infection with the parasite Schistosoma haematobium.

PDQ describes how bladder cancer typically presents, and those signs remain the ones that matter during follow-up.

The usual sign is hematuria, meaning blood in the urine. It may be visible or seen only under a microscope. Less often, people report passing urine frequently, getting up at night to go, and pain on passing urine. PDQ notes those three are more common with carcinoma in situ.

Any of them appearing during surveillance is a reason to contact the urology team rather than wait for the next scheduled cystoscopy.

For people whose bladder was removed, PDQ describes the reconstructive approach. Surgeons build low-pressure storage reservoirs from reconfigured small and large bowel. These remove the need for external drainage devices. In many patients they also allow voiding through the urethra. PDQ says the goal is better quality of life for people who need a cystectomy.

That is where this summary ends on the topic. PDQ does not address vitamin B12 monitoring. It does not address testing for acid buildup in the blood. It does not give stoma care schedules for a urinary diversion. Those are real questions. They need an answer from the surgical or ostomy team, not from this source.

For people who kept their bladder, PDQ sets out three tiers for non-muscle-invasive disease.

• Surveillance alone, for tumors at low risk of return or progression.
• A minimum of 1 year of BCG inside the bladder, plus surveillance, for tumors at intermediate or high risk of progression.
• More chemotherapy inside the bladder, for tumors at high risk of return but low risk of progression.

The disease itself is described in bladder cancer. The broader life-after-treatment picture is in survivorship. One of the chemicals named above is covered in benzidine and cancer.

• NCI PDQ: bladder cancer, HP version