Bladder Cancer Diagnosis & Treatment in Singapore

Bladder Cancer Treatment: Surgery

Surgery is a common treatment for bladder cancer and can involve procedures such as transurethral resection of bladder tumour (TURBT) to remove small tumours, partial or radical cystectomy to remove part or all of the bladder, and urinary diversion techniques for redirecting urine flow after bladder removal.

Transurethral resection of bladder tumour (TURBT):

• A procedure performed using a cystoscope inserted through the urethra to remove small tumours confined to the inner layers of the bladder.
• It is commonly used for diagnosing and treating early-stage bladder cancer.
• It can also be used as a therapeutic procedure to remove larger tumours that are not deeply invasive.

Partial or radical cystectomy:

• Partial cystectomy involves removing only a portion of the bladder while preserving its function. This option is suitable for certain cases where the cancer is localised and limited.
• Radical cystectomy involves removing the entire bladder, nearby lymph nodes, and sometimes other surrounding organs if the cancer has spread.
• In both procedures, reconstruction techniques, such as creating an ileal conduit or neobladder, may be used to redirect urine flow after bladder removal.

Lymphadenectomy:

• In cases where bladder cancer has a high risk of spreading to nearby lymph nodes, a lymphadenectomy may be performed.
• Lymphadenectomy involves the removal of lymph nodes in the pelvis to reduce the risk of cancer recurrence or metastasis.

Bladder Cancer Treatment: Radiation Therapy

Radiation therapy is a common treatment option for bladder cancer. 

(A) External Beam Radiation Therapy: This involves using a machine called a linear accelerator to deliver high-energy X-rays to the tumour from outside the body. The radiation beams are carefully targeted to the bladder, aiming to kill cancer cells while minimising damage to surrounding healthy tissues.

(B) Internal Radiation Therapy (Brachytherapy): Radioactive material, such as seeds or wires, is temporarily placed inside the bladder. These radioactive sources emit radiation directly to the tumour, delivering a concentrated dose of radiation while sparing healthy tissues.

(C) Combination Therapy: Radiation therapy can be combined with other treatments, such as surgery or chemotherapy, to increase effectiveness. It may be used before surgery (neoadjuvant therapy) to shrink tumours or after surgery (adjuvant therapy) to target any remaining cancer cells.

(D) Palliative Radiation Therapy: In advanced cases or when bladder cancer has spread, radiation therapy can be used to alleviate symptoms, such as pain, bleeding, or urinary obstruction, and improve quality of life.

Bladder Cancer Treatment: Chemotherapy

Chemotherapy is a treatment option for bladder cancer that uses drugs to kill cancer cells or slow down their growth. 

(A) Intravesical Chemotherapy: Chemotherapy drugs are directly instilled into the bladder through a catheter. This method is often used for early-stage bladder cancer or to prevent recurrence after tumour removal. Common drugs used include mitomycin C or bacillus Calmette-Guérin (BCG).

(B) Systemic Chemotherapy: Drugs are given intravenously or orally to target cancer cells throughout the body. Systemic chemotherapy may be used before or after surgery, or in advanced cases where cancer has spread beyond the bladder. The choice of drugs and regimen depends on the specific characteristics of the cancer and the patient’s overall health.

(C) Combination Therapy: Different chemotherapy drugs can be combined to enhance their effectiveness. Combination chemotherapy is commonly used in advanced bladder cancer to improve treatment outcomes. Platinum-based drugs, such as cisplatin or carboplatin, are often used in combination with other drugs like gemcitabine or paclitaxel.

(D) Neoadjuvant and Adjuvant Chemotherapy: Neoadjuvant chemotherapy is given before surgery to shrink tumours and increase the likelihood of successful surgery. Adjuvant chemotherapy is administered after surgery to target any remaining cancer cells and reduce the risk of recurrence.

Bladder Cancer Treatment: Targeted Therapy

Targeted therapy is an emerging treatment approach for bladder cancer that aims to specifically target certain genetic mutations or pathways in cancer cells. 

(A) Molecular Targeted Therapy: Targeted therapy drugs are designed to block specific molecules or pathways involved in the growth and spread of cancer cells. These drugs work differently than traditional chemotherapy by specifically targeting cancer cells while sparing normal cells.

(B) FGFR Inhibitors: Fibroblast growth factor receptor (FGFR) inhibitors are a type of targeted therapy used for bladder cancer with specific genetic alterations in FGFR genes. Drugs like erdafitinib or pemigatinib are used to inhibit abnormal FGFR signaling and slow down cancer growth.

(C) PD-1/PD-L1 Inhibitors: Immune checkpoint inhibitors, such as pembrolizumab or atezolizumab, are targeted therapy drugs that enhance the immune system’s ability to recognise and attack cancer cells. 

(D) HER2 Inhibitors: Bladder cancers that overexpress human epidermal growth factor receptor 2 (HER2) may benefit from targeted therapy drugs like trastuzumab or pertuzumab. These drugs specifically target HER2-positive cancer cells and interfere with their growth signals.

Targeted therapy drugs can be used in combination with other treatment modalities like chemotherapy or immunotherapy to maximise treatment effectiveness. 

Bladder Cancer Treatment: Immunotherapy

Immunotherapy is a type of bladder cancer treatment that works by boosting the body’s immune system to recognize and attack cancer cells. 

Immune Checkpoint Inhibitors: Immunotherapy drugs called immune checkpoint inhibitors, such as pembrolizumab or atezolizumab, are used in bladder cancer treatment.

Immunotherapy can lead to durable responses and long-term control of bladder cancer. It is used in advanced cases when cancer has spread or as an option when other treatments have not been effective. However, not all patients respond to immunotherapy, and the effectiveness may vary from person to person.

 Are there any Side Effects of Bladder Cancer Treatment?

Side Effects of Bladder Treatment: Surgery

Surgery is a common treatment for bladder cancer and, like any medical procedure, it can have potential side effects. Here are some common side effects associated with bladder cancer surgery:

• Pain and Discomfort: Following surgery, it is normal to experience pain and discomfort at the surgical site. 
• Urinary Incontinence: Depending on the extent of the surgery, there may be temporary or permanent changes in urinary control, leading to urinary leakage or incontinence. 
• Urinary Retention: In some cases, bladder surgery may result in difficulty emptying the bladder completely, requiring the use of a catheter or other interventions.
• Sexual Dysfunction: In both men and women, bladder cancer surgery can sometimes affect sexual function. This may include changes in sexual desire, erectile dysfunction in men, or vaginal dryness and discomfort in women. 
• Bowel Changes: Surgery involving the bladder can affect bowel function. Some individuals may experience changes in bowel movements, such as diarrhea or constipation. 
• Surgical Complications: As with any surgical procedure, there is a risk of potential complications, such as bleeding, infection, blood clots, or damage to surrounding organs or structures.

Side Effects of Bladder Cancer Treatment: Radiation Therapy

Radiation therapy is a common treatment for bladder cancer, and it can have certain side effects. Here are some common side effects associated with bladder cancer treatment using radiation therapy:

• Urinary Symptoms:

1. Increased Frequency and Urgency: Radiation therapy can cause irritation and inflammation of the bladder, leading to increased frequency and urgency of urination.
2. Painful or Burning Sensation: Some patients may experience discomfort or a burning sensation during urination.

• Fatigue: Radiation therapy can cause fatigue, making patients feel tired and lacking energy. 
• Skin Changes: The skin in the treated area may become red, irritated, or sensitive. It may resemble a sunburn and may be itchy or dry.
• Gastrointestinal Issues: Radiation therapy to the pelvic area can affect the gastrointestinal system, resulting in side effects such as:
• Diarrhea: Radiation can cause an increase in bowel movements and loose stools.
• Rectal Discomfort: Some patients may experience rectal pain, irritation, or bleeding.
• Sexual Dysfunction: Radiation therapy to the pelvic region can sometimes affect sexual function, leading to erectile dysfunction in men or vaginal dryness and discomfort in women.
• Bladder or Bowel Strictures: In some cases, radiation therapy can cause scarring or narrowing of the bladder or bowel, leading to difficulties with urination or bowel movements.
• Long-Term Effects: Rarely, radiation therapy for bladder cancer may result in long-term side effects such as bladder or bowel damage, chronic inflammation, or an increased risk of secondary cancers.

Side Effects of bladder Cancer Treatment: Chemotherapy

Chemotherapy, a common treatment for bladder cancer, can have certain side effects. Here are some common side effects associated with bladder cancer treatment using chemotherapy:

• Nausea and Vomiting: Chemotherapy drugs can affect the digestive system, leading to nausea and vomiting. Medications can be prescribed to help manage these side effects.
• Hair Loss: Some chemotherapy drugs can cause temporary hair loss, including hair on the scalp, eyebrows, and body. Hair usually grows back once treatment is completed.
• Fatigue: Chemotherapy can cause fatigue, making patients feel tired, weak, or lacking energy. 
• Decreased Blood Cell Counts:

1. Anaemia: Chemotherapy can lower red blood cell counts, resulting in anaemia. This can cause fatigue, shortness of breath, and weakness.
2. Increased Risk of Infection: Chemotherapy can reduce the number of white blood cells, which are important for fighting infections. This can increase the risk of infections.

• Increased Bruising or Bleeding: Chemotherapy can affect platelet counts, leading to an increased risk of bruising or bleeding.
• Mouth Sores: Some chemotherapy drugs can cause mouth sores or ulcers, making it uncomfortable to eat or drink. 
• Peripheral Neuropathy: Certain chemotherapy drugs can cause peripheral neuropathy, which is characterized by numbness, tingling, or pain in the hands and feet.
• Changes in Appetite and Taste: Chemotherapy can affect the sense of taste, causing changes in appetite or taste preferences.

 Side Effects of Bladder Cancer Treatment: Targeted Therapy

Targeted therapy is a newer treatment approach for bladder cancer, and it can have certain side effects. Here are some common side effects associated with bladder cancer treatment using targeted therapy:

• Fatigue: Targeted therapy drugs can cause fatigue or a general feeling of tiredness. 
• Skin Rash or Reactions: Some patients may develop a rash or experience skin reactions, such as dryness, itching, or redness. 
• Gastrointestinal Issues: Targeted therapy drugs can cause gastrointestinal side effects, including diarrhea, nausea, vomiting, or loss of appetite.
• High Blood Pressure: Certain targeted therapy drugs may lead to an increase in blood pressure. 
• Liver Toxicity: Some targeted therapy drugs can affect the liver and lead to liver function abnormalities. 
• Blood Clotting Disorders: In rare cases, targeted therapy drugs can increase the risk of blood clot formation, which can lead to serious complications. 
• Allergic Reactions: Although rare, allergic reactions to targeted therapy drugs can occur. Symptoms may include difficulty breathing, swelling, rash, or severe itching. 
• Cardiac Toxicity: Some targeted therapy drugs may have an impact on the heart, leading to changes in heart rhythm or function. Regular cardiac monitoring may be required.

Side Effects of Bladder Cancer Treatment: Immunotherapy

Immunotherapy, a treatment option for bladder cancer, can have certain side effects. Here are some common side effects associated with bladder cancer treatment using immunotherapy:

• Fatigue: Immunotherapy drugs can cause fatigue or a general feeling of tiredness. 
• Skin Rash or Reactions: Some patients may develop a rash or experience skin reactions, such as itching, redness, or dryness. 
• Flu-like Symptoms: Immunotherapy can cause flu-like symptoms, including fever, chills, body aches, or headache. 
• Gastrointestinal Issues: Some patients may experience diarrhea, nausea, vomiting, or loss of appetite as a result of immunotherapy treatment.
• Endocrine-related Side Effects: Immunotherapy drugs can occasionally affect the endocrine system, leading to hormonal imbalances. 
• Immune-related Side Effects: Immunotherapy works by stimulating the immune system, which can occasionally lead to immune-related side effects known as immune-related adverse events (irAEs). These can affect various organs and systems in the body, such as the lungs (pneumonitis), liver (hepatitis), intestines (colitis), or endocrine glands (hypophysitis).
• Autoimmune Reactions: In rare cases, immunotherapy can trigger autoimmune reactions, where the immune system mistakenly attacks healthy cells or organs. This can lead to conditions such as autoimmune hepatitis, thyroiditis, or type 1 diabetes.

What Do I Need to Do If I have Bladder Cancer?

It is important to remember that bladder cancer can be treated successfully if caught early. If you have any concerns about your bladder health or notice any changes, do not hesitate to see a healthcare professional for evaluation.

If you suspect that you or your loved one have bladder cancer, it is advisable to get the support you need. Early detection and diagnosis of bladder cancer is key to treating the disease. 

Regardless of what stage your bladder cancer may be at, you should schedule an appointment to see an oncologist specialising in bladder cancer as soon as possible. With the speed of developments in bladder cancer diagnosis and treatment, novel emerging treatment options could be explored by your medical oncologist. 

Our cancer specialists at OncoCare specialise in treating late stage and advanced stages of bladder cancer, as well as earlier stages of the disease.

What is Bladder Cancer?

Definition of Bladder Cancer

Bladder cancer is a type of cancer that begins in the cells of the bladder, which is a hollow organ in the lower abdomen that stores urine. The most common type of bladder cancer is urothelial carcinoma, also known as transitional cell carcinoma, which starts in the urothelial cells that line the inside of the bladder.

There are several types of bladder cancer, including:

• Urothelial Carcinoma: This is the most common type, accounting for most bladder cancer cases. It begins in the urothelial cells that line the bladder and can also affect other parts of the urinary tract, such as the ureters or urethra.
• Squamous Cell Carcinoma: This type of bladder cancer starts in the squamous cells, which are flat cells that may form in response to long-term irritation or inflammation of the bladder, such as from chronic urinary tract infections or long-term use of a urinary catheter.
• Adenocarcinoma: Adenocarcinoma of the bladder is a rare form of bladder cancer that develops in the glandular cells of the bladder. It can be linked to conditions such as chronic bladder inflammation or certain congenital abnormalities.

Less common types of bladder cancer include small cell carcinoma, sarcoma, and lymphoma. These types are relatively rare and account for a small percentage of bladder cancer cases.

Bladder cancer is a significant global health concern. It ranks as the 10th most common cancer worldwide, accounting for around 3.2% of all new cancer cases. The disease primarily affects older individuals, with most cases occurring in people over the age of 55. The global mortality rate for bladder cancer is estimated to be approximately 2.8%. 

In Singapore, bladder cancer is particularly prominent among males, ranking as the 5th most common cancer. However, it is less prevalent among females. In 2020, there were 1,004 new cases of bladder cancer reported in Singapore. The incidence rate stands at around 4.7 cases per 100,000 population, with a mortality rate of approximately 2.3 per 100,000 population. 

These statistics provide a general overview of bladder cancer’s prevalence and impact both worldwide and in Singapore, emphasising the need for continued research, early detection, and effective treatment strategies to combat this disease.

What are the Signs and Symptoms of Bladder Cancer?

Signs and symptoms of bladder cancer can vary, and some individuals may not experience any symptoms in the early stages.

The most common symptoms of Bladder Cancer include:

• Hematuria (Blood in Urine): The most common and noticeable symptom of bladder cancer is blood in the urine, also known as hematuria. Blood may appear either grossly (visible to the naked eye) or microscopically (detected only during urine testing). Hematuria is typically painless.
• Frequent Urination: Bladder cancer can cause an increased urge to urinate frequently. This can be accompanied by a sense of urgency or discomfort during urination.
• Pain or Burning Sensation: Some individuals with bladder cancer may experience pain or a burning sensation during urination. This can be a result of irritation or inflammation caused by the tumour.
• Lower Back or Pelvic Pain: Advanced bladder cancer may cause pain in the lower back or pelvis. This pain can be persistent and may worsen over time.
• Changes in Urinary Habits: Bladder cancer can lead to changes in urinary habits, such as increased frequency, urgency, or difficulty emptying the bladder completely.
• Fatigue and Weight Loss: In some cases, bladder cancer may cause fatigue and unexplained weight loss. These symptoms are more commonly associated with advanced stages of the disease.

It’s important to note that these symptoms can also be caused by other non-cancerous conditions, such as urinary tract infections or bladder stones. However, if any of these symptoms persist or cause concern, it is crucial to consult a healthcare professional for a proper evaluation and diagnosis. 

Screening for Bladder Cancer

Unlike some other cancers, there are no standard screening tests recommended for the general population to detect bladder cancer in its early stages. This is because there is currently insufficient evidence to support the effectiveness of routine screening for bladder cancer in individuals without any specific risk factors or symptoms.

However, in certain high-risk individuals, such as those with a history of bladder cancer or exposure to certain occupational hazards, regular screening or surveillance may be recommended. The specific screening or surveillance strategies may vary based on individual risk factors and medical history. 

In general, if you have any symptoms suggestive of bladder cancer, such as blood in the urine (hematuria), frequent urination, or persistent urinary tract infections, it is important to consult a healthcare professional for a proper evaluation. They may perform tests such as urine analysis, imaging studies (like ultrasound or CT scan), or cystoscopy (a procedure to examine the bladder using a thin tube with a camera) to help diagnose or rule out bladder cancer.

Additionally, it’s worth noting that reducing exposure to known risk factors for bladder cancer, such as quitting smoking and minimising occupational exposure to certain chemicals, can help lower the risk of developing the disease.

 What are the Stages of Bladder Cancer?

Bladder cancer staging refers to the process of determining the extent and spread of the cancer within the bladder and to nearby organs or lymph nodes. The stages of bladder cancer are typically classified using the TNM system, which stands for Tumour, Nodes, and Metastasis. The stages range from non-invasive (limited to the inner lining of the bladder) to invasive (spreading into deeper layers of the bladder or beyond). Here is a general overview of the stages of bladder cancer:

• Stage 0 (Carcinoma in Situ, CIS): The cancer is confined to the innermost layer of the bladder lining and has not invaded the bladder muscle or spread to nearby lymph nodes or distant sites.
• Stage I: The cancer has grown into the connective tissue layer beneath the bladder lining but has not reached the muscle layer or beyond. It has not spread to lymph nodes or distant sites.
• Stage II: The cancer has invaded the muscle layer of the bladder but has not spread beyond the bladder walls. It has not reached lymph nodes or distant sites.
• Stage III: The cancer has grown through the bladder muscle and may have spread to the fatty tissue surrounding the bladder. It may involve nearby organs or lymph nodes, but it has not spread to distant sites.
• Stage IV: This is the most advanced stage of bladder cancer. It indicates that the cancer has spread beyond the bladder to nearby organs, lymph nodes, or distant sites, such as the bones, liver, or lungs.

Staging plays a crucial role in determining the appropriate treatment options and predicting the prognosis for bladder cancer patients. Various diagnostic tests, such as imaging, biopsies, and sometimes surgical exploration, are done to accurately determine the stage of bladder cancer in each individual case.

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