Bladder Cancer Detection
Bladder Cancer Detection
Bela Denes (Urologist) gives expert video advice on: At what age should I start getting screened for bladder cancer?; Is blood in the urine always an indication of bladder cancer? and more...
At what age should I start getting screened for bladder cancer?
It depends on whether you smoke or not, it depends on what you do, and what your chemical exposure is. Unless you are at risk based on those risk factors, there is no recommended screening age currently. Bladder cancer is generally a disease of middle and later ages, although it can occur even in early adulthood and the late teenage years. As part of a good health program, annual checkups that you start to have when youre 40-45, 50, a urinalysis should be part of that examination to check for bladder infections, to check for protein in the urine which may indicate kidney disease, to check for sugar in the urine which may be a sign of diabetes, and also to check for blood in the urine, which may be a sign of bladder cancer. Specifically, there are no strong set screening recommendations for bladder cancer, except for high risk individuals.
How will my doctor make a bladder cancer diagnosis?
Bladder cancer, today, is typically diagnosed by an examination called a cystoscope or cystoscopic examination. This is an actual direct visualization of the inside of the bladder. It is done, in this country, in the doctors office or in the doctors clinic. It is a very quick examination. It is a minimally-uncomfortable examination with the scopes that we have today. The scopes that we have today are small-caliber, and they're flexible. The examination generally takes anywhere from three to ten minutes, and within that span of time, the doctor with have a thorough look at all parts of lower urinary tract and bladder, as well as the urethra, and look for the source of bleeding, and should be able to identify a tumor if there is one there.
What is 'hematuria'?
Hematuria is the medical term that refers to blood in the urine. Hematuria can be gross, which means it's visible to the naked eye. It can also be called macroscopic, large size or microscopic. One that is not visible to the naked eye, but only detected either under microscopic examinations of the urine or detection by a districreagent.
Is blood in the urine always an indication of bladder cancer?
No, it's not. In fact, most patients who have blood in the urine generally do not have bladder cancer. There are many other causes of blood in the urine, from kidney stones, which are much more common than bladder cancer, whether they are in the kidney, the ureter or the bladder; kidney cancer, or renal cell carcinoma, which is not related to bladder cancer can present with blood in the urine. There are congenital malformations, and also developmental abnormalities of the kidney such as cystic malformation of the kidney that can be associated with blood in the urine. And finally, there are lots of patients today who take blood thinners because to lower their risk of either cardiovascular disease, heart attack or stroke, who are on long-term anticoagulants. These anticoagulant levels need to be monitored generally on a every 2-week to once a month basis. And often if theyre not monitored closely, the blood will become too thin and patients will present with blood in the urine as a sign not that they have a urinary tract problem but that their anticoagulant needs to be adjusted.
What are 'upper tract studies'?
The urinary tract, by medical convention, is divided into the upper and the lower tract. The upper tract refers to the kidney and the ureters, down to the point where they enter the bladder. The lower urinary tract refers to the bladder and the urethra. Upper tract studies are examinations that are designed to either examine the function or the anatomy of the upper urinary tract, that is the kidney, the pelvis of the kidney, or the renal pelvis, and the ureters.
When are upper tract studies used?
Upper track studies are used when there is a suspicion that there may be a tumor above the bladder, either on the ureter or the renal pelvis, that is the source of the bleeding or the abnormal cells in the urine. Upper track studies are also used for patients who have rapidly recurrent lower tract tumors, which are tumors within the bladder, where we want to make sure that the upper tracts are normal and that there's not a source of tumor above the bladder. These bladder tumors are referred to as transitional cell carcinomas. The transitional cell itself is the cell that lines the entire urinary tract – both the upper as well as the lower tract. Thus, someone who has a disposition or a predisposition to developing a transitional cell carcinoma in the bladder is felt to have had his entire urinary tract at risk. At some point, most patients will have some upper tract studies, whether that's dye injected directly into the ureters during the course of assisted scopic examination, a CAT scan or an MRI, or some sort of examination of the upper urinary tract to make sure that there's no problems above.
What is 'fluorescence cystoscopy'?
Fluorescence cystoscopy refers to a technique of examining the bladder with a cystoscope. However, instead of using ambient or white light, which is used in conventional cystoscopy to examine the different areas of the bladder, a fluorescent dye is introduced into the tumor, prior to the cystoscopic examination, and then a green light is used during the exact examination. The advantage of this is that certain tumors are virtually undetectable by conventional cystoscopy, because they don't grow in from the wall, or out from the wall, of the bladder. There is no actual growth that's visible. They're flat tumors, commonly known as Carcinoma in Situ. During conventional cystoscopy, about 10% or 15%, maybe 20%, of these tumors will be missed because they don't look different from the surrounding tissue. If someone has had some previous surgery, or has had some infections, or an inflammation of the bladder, they'll be missed. With fluorescence cystoscopy, they stick out like a sore thumb, because when you turn the green light on, the entire bladder looks black, except for one area where the dye itself is concentrated by the tumor cells.
What are the downsides of fluorescence cystoscopy?
Previously, the downside to this type of examination was that the dyes that were used to help fluoresce the tumor were only available as injectable. You had to give the dye intravenously, let it circulate through the body, concentrate in the bladder, and bring the patient back for the green light examination. After the examination, since the dye was given intravenously and systemically, the patients had to avoid daylight exposure for several days for fear of a photosensitizing type of a reaction. The good news is that there are now currently in development, even in research studies conducted in this country, a new type of administration of the fluorescent dye. Instead of giving it intravenously, it's directly administered into the bladder prior to the examination. After the examination, it's evacuated from the bladder. This works well, and the patients no longer have that risk of systemic photosensitization. It is expected that this will increase the accuracy of cystoscopic examination by anywhere from 15 to perhaps as much as 30 percent.
Is cystoscopy painful?
Cystoscopy is the passage of a small scope through the normal urethral opening. It is different in men and women. Cystoscopy in a woman is done without anesthesia. It is virtually painless. A little bit of lubricant is used to help ease the introduction of the scope. Lubricant with some lidocaine gel is also used to help faciltate any discomfort - to facilitate passage of the scope. In women, it generally is not an issue. Most women are quite comfortable, unless you overextend the bladder, but the procedure itself is well tolerated. It is more of a challenge in men due to anatomic changes, but using today's instruments, which are small caliber and flexible, and by using a topical, local anesthetic prior to instrumentation, most men tolerate the procedure without any problem or difficulty.
Are there any urine tests for bladder cancer?
The most commonly employed urine test right now is called urine cytology, which is simply collecting urine. Generally, it is first morning urine that's collected in a container, which is then sent to the pathologist. The specimen itself is ultra-centrifuged - it's spun down very fast to collect any loose cells in the urine, and a specially trained cytopathologist examines it to look for malignant cells. Cytology has been around for a long time. The downside of cytology is that it is very sensitive and reasonably accurate in patients who have high grade and high stage tumors. However, it is not reliable - in the 15-20% range - in diagnosing patients who have low grade, low stage tumors, and most patients with bladder cancer present with low grade, low stage tumors. Additional urine diagnostic or screening tests are in development now, based on proteins that are either secreted by tumors, or enzymes that are secreted by tumors. There are a number of new diagnostic or screening tests that are in development and will soon be available. Many of them are available today. Combining one of these urinary diagnostic tests with cystoscopy often raises the accuracy of the examination. Using one of these diagnostic tests combined with cystoscopy will alert the urologist that the tumor may not be in the bladder, but somewhere else in the urinary tract. If he examines the bladder and doesn't see an obvious tumor within the bladder, and yet the cytopathologist keeps telling him that there are malignant cells in the urine, then he has to start examining the ureters or the renal pelvis, to see if there is an upper tract source of tumor.