Bladder Cancer Prognosis
Bela Denes (Urologist) gives expert video advice on: What's the survival rate for women diagnosed with bladder cancer?; Do men or women have a better chance of surviving bladder cancer?; If left untreated, how long can someone live with bladder cancer? and more...
What's the average prognosis for someone diagnosed with bladder cancer?
The overall prognosis for bladder cancer remains very positive, promising and good. That's because most patients who present with bladder cancer, present with low-grade, superficial, or non-muscle-invasive bladder cancer that can be handled by resecting the involved area in the bladder, removing the tumor, and then either with or without additional therapy and close observation, keep the patient essentially tumor free. For those patients, their 5 year prognosis, although not 100%, certainly approaches 90%. The downside is that although the deathrate, or the survival rate is high and the death rate is low, the recurrence rate is around 60-70%, so those patients need very close, careful, and continuous follow-up. And yet the progression rate is also in the 10-15%, so you have to work closely with your pathologist in terms of making sure that all tumors are resected, that all tumors are properly assessed and evaluated, for the best possible outcome.
What do the various stages of bladder cancer diagnosis mean?
All cancers, including bladder cancer, are staged. What staging refers to, essentially, is categorizing the disease at its presentation, both in terms of its extent, as well as its involvement, and the reason for this is to be able to give treatment recommendations based on good, sound judgement, and based on previous experience. Most patients with bladder cancer present with low grade, Stage One or Stage T1 disease. A few patients present with T2 disease, some have T3 and a few have T4. If we didn't have these kind of staging conventions, if you just came in and said "You've got bladder cancer, I'm going to take your bladder out", most patients would be way over-treated, because only patients who have a more invasive disease need to have their bladder removed. On the other hand, if you didn't have the staging convention and you examined someone's bladder and said, "Well, you've got bladder cancer, I'm just going to put medication into your bladder", you'd under-treat a large number of patients who would need to have their bladder removed. Staging is a convention where we can, based on solid data, based on published data, we can make solid and responsive treatment recommendation. Staging is also a convention where we can learn the behaviour of the disease, and we can see what theraputic or treatment options work better for certain stages and not for others. Finally, a stage is a way where physicians can discuss amongst themselves what therapy seems to be working, so that we make sure we're all talking about apples and apples, and not apples and oranges.
What are 'bladder cancer grades'?
Grade of tumor in bladder cancer, as in many other tumors refers, not to how extensive the tumor is, but to how aggressive the individual cancer cell appears to the pathologist under the microscope. Most cancer cells are thought to start out as slight variations of normal tissue, and as the cancer becomes more aggressive, due to whatever DNA problems the cell encounters, it becomes much more aggressive, much more wild-looking, and the cell itself no longer resembles the cell line it started from. If you put a low-grade transitional cell carcinoma next to a normal transitional cell, it takes a very experienced pathologist to be able to note the subtle differences between those cells - between the size of the cell, the size of the nucleus, and the appearance of the nucleus - where he can say, "Yeah, thats a cancer cell, but it's the low-grade cell", versus one of these high-grade cells that looks so wild that at times it's impossible for the pathologist to even identify the tissue that it originated from, other than being told that this was a bladder tumor that was removed. High-grade and high stage tend to go hand in hand - in other words more aggressive tumors - more histologically aggressive tumors - tend to exhibit more aggressive behavior in terms of invasion and progression, whereas low-grade tumors tend to have a little bit more of an indolent course.
What's the survival rate for men diagnosed with bladder cancer?
If you take all men with bladder cancer, the survival rate at 5 years is about 75%. Obviously, that mixes in men who have low grade, low stage disease - lower risk disease - versus men who have intermediate risk and high risk disease. There is also a slight difference between the prognosis for Caucasians versus Hispanics, Asians, and African Americans. Overall, that's about the survival rate for the group as a whole.
What's the survival rate for women diagnosed with bladder cancer?
Overall, the survival rate for women with bladder cancer tends to be lower than men with bladder cancer by about 5 to 10 percent, so it's in the 65 percent range. It's not clear why this is - there are generally two thoughts on it, one is that women tend to perhaps have a little bit of a delay in their diagnosis due to the fact that the diagnosis is often confused with bladder infections, but the other is that although anatomically the bladder of a woman is very similar to that of a man in terms of having the same layers or the same number of layers in it. Generally, the female bladder is much thinner, and it doesn't have the muscular back wall that the male bladder has for a number of reasons, including the prostate related issues. Since the female bladder is significantly thinner than the male bladder, the cancers tend to become more invasive earlier, be of smaller volume, and have more access to the lymphatics in the vasculator.
Do men or women have a better chance of surviving bladder cancer?
Statistics would show that men have survival rates that are 5 to 10 percent higher than for women. It is not clear why this is but the prevailing thoughts are that women tend to be diagnosed a little bit later. There tends to be a delay in diagnosis due to a number of factors, such as being treated for bladder infections. Also, the male and female bladder are slightly different anatomically. When you look at the bladders side by side or microscopically, they have the same type of cells in the same number of layers. The female bladder is much thinner than the male bladder, especially in its muscular wall. Once the tumor reaches the muscle, it's easy for it to penetrate to the outside, so the fact that the female bladder tends to be significantly thinner than the comparable male bladder may be an easier progression for the bladder tumor.
What does 'stage 0 bladder cancer' mean?
Stage zero today refers to somebody who has had a tumor resected. Either that portion of the bladder is removed, as in a segmental cystectomy, or the urologist decides to go back and resect that area again, to make sure that there's no residual tumor, and the pathologist reports that in the specimen he has examined, no tumor is identifiable. That's what's currently referred to as stage zero. The lowest stage that we refer to, the lowest risk, the most superficial is called stage T, stage A or TA bladder cancer.
What does 'carcinoma in situ' or 'CIS' mean?
CIS stands for carcinoma in situ. In most cancers, cervical cancer for instance, it's thought to be a pre-malignant stage. In other words, it is just before the tumor becomes frankly malignant. In bladder cancer, CIS is a little bit of a misnomer. Although there's often no visible growth at systoscopic examination, other than an area of perhaps some slight reddening, or some slight swelling or edema, or a mossy kind of a look to that area, the individual cells in carcinoma in situ of the bladder are much more aggressive cytologically than low-grade bladder cancer. Carcinoma in situ is a unique cancer in bladder cancer, and it doesn't fit the normal staging. Patients who have carcinoma in situ don't do very well with surgery alone, because it's virtually impossible to distinguish the area where this tumor is involved from the adjacent normal area. There's no clear-cut growth to remove, so the mainstay of therapy right now for carcinoma in situ is surgical resection or cauterization of any visible lesions or identified lesions. Intensive intervesicle therapy, either with BCG or with a combination of interferon and BCG, is to control the disease.
What does 'stage 1 bladder cancer' mean?
Stage one bladder cancer is now sub-divided into what's called TA or T1. Stage one or T1 bladder cancer is a superficial tumor, but it's exhibiting some malignant behaviour by showing that there's some growth in the lining of the bladder itself. The tumor is no longer just growing out or sprouting out from the lining of the bladder, but there are tumor cells that are seen infiltrating into the lining area of the bladder. Just below the lining cells, there's an area called the lamina propria, and a T1 tumor has grown or penetrated that lamina propria.
What does 'stage 2 bladder cancer' mean?
Stage 2 bladder cancer is an invasive bladder cancer. It is muscle invasive. The designation 2 means that tumor cells are identified within the bladder muscle itself. It is subdivided into 2a or b, depending on the depth of invasion, but that is not so material for endoscopic or trans-urethral resection, because it is very hard to gage the depth of the penetration based on the scooping out, scraping or resecting of the tumor. But what the presence of Stage 2 tumor means is that that patient is destined to have aggressive disease, and needs to strongly consider cystectomy.
What does 'stage 3 bladder cancer' mean?
Stage 3 bladder cancer refers to a tumour that is no longer contained within the bladder, but has penetrated through not only the bladder muscle, but the outer wall of the bladder. It is subdivided into A and B. 'A' refers to microscopic cells that are found outside of the bladder at the time of cystectomy, when the pathologist does the examination. 'B' or 'D3B' disease is when the surgeon himself can visually or by tactile feel, identify a tumour. It's more of a gross evaluation of the bladder. That is what constitutes D3 disease.
What does 'stage 4 bladder cancer' mean?
Stage 4 bladder cancer refers to bladder cancer that has metasticized or spread from the bladder, the organ where it originated. Typically, bladder cancer spreads either through the lymph nodes or through the vascular system by gaining access to blood vessels. If it spreads through the lymph nodes, of course, it can enter the systemic circulation. If it enters the vasculature directly, then the cancer cells can spread throughout the body, and then implant into the bones, the skeleton, the lungs, the liver, the brain - much like any other tumor.
Where does bladder cancer tend to spread?
Bladder cancer can spread through the whole body through the Lymphatic System or the Vascular system. Cancer cells will implant in any organ - most commonly in the liver, lungs, brain and skelatal system.
If left untreated, how long can someone live with bladder cancer?
The biologic behavior of bladder cancer depends on the stage that it presents, in terms of the grade of the tumor. High grade, high stage bladder cancer, patients who present, for instance, with Stage III or Stage IV bladder cancer, have a very limited lifespan. Their five-year for Stage IV bladder cancer, even with chemotherapy, the prognosis is in the 15 or 18% range of five years, so with no treatment it would be less than that. Patients with low stage bladder cancer would have a much better long-term prognosis. However, the presenting sign and symptom of bladder cancer is bleeding, so these patients tend to have recurrent bleeding, and sometimes require transfusions - blood clots that obstruct the bladder - and they have to have catheterizations to remove clots. Although it would be a slow progressive disease, the recurrence rates are high. The tumor is going to recur and eventually progess, but it would be much more in the order of 10 to 15 years than 5 years.
What kind of quality of life can I expect with bladder cancer?
The quality of life with bladder cancer is reasonably good for most patients, partly due to the fact that most patients have low-grade, non-invasive or superficial bladder cancer, and the treatment for that bladder cancer tends to be local. It's either transurethral resection, followed by some immediate chemotherapy; or it's surgery followed by weekly installations into the bladder, and then continued surveillance with periodic maintenance installations into the bladder. There is the inconvenience of having to start to create this kind of an agenda, or schedule to your life, that the procedures themselves are reasonably well tolerated. Most of them are done as an outpatient, even when some kind of a surgical resection is required. The intravesical or the bladder installations are all generally done in an office or an outpatient clinic. There's very little in-hospital time involved for most patients. They're able to generally adjust their schedule and lead relatively normal lives. A few patients, however, do get complications from the treatment, especially BCG, which causes an inflammation, and can cause some constriction to the bladder, painful urination, recurrent bleeding. However, the quality of life for most patients with bladder cancer is reasonably good.
Will I be incontinent because of bladder cancer?
Most patients who have bladder cancer are not incontinent. Immediately following a procedure on your bladder, whether it's a transurethral resection or a laser procedure, fluorescent cystoscopy, or intravascular installation, you may have some strong urgency associated with your bladder, because the treatments are irritating to the bladder, and your bladder is not going to be as compliant. The bladder is not going to be able to hold as much urine, so there may be a little bit more urgency, and you may have some incontinent episodes in that very immediate post-treatment or post-operative period. Generally, incontinence is not a problem with either bladder cancer or the treatments for bladder cancer. With the newer bladder replacement surgical strategies, where a new bladder is essentially created by sewing a portion of the small intestine together and then bringing it down into the pelvis, incontinence is a problem because the patient essentially has to learn how to urinate all over again. The bowel was not made to hold urine; the bowel does not have the neural pathway to send a message to the brain up through the spinal cord, to let you know that it's full. It is a whole new set of sensations that have to be learned, and a new whole new set of mechanistic approaches to voiding have to be taught to those patients.
What is the long-term prognosis for people with bladder cancer?
The prognosis for bladder cancer is similar to the prognosis for any cancer. A lot of it is dependant on the extent of the cancer when it's first diagnosed, what we would call the stage of the cancer at diagnosis, and the grade of the tumor at diagnosis. As is true for most cancers, patients with low grade, low stage tumors tend to do better than patients with high grade, high stage tumors. Earlier diagnosis is preferred to late diagnosis. Patients with low stage, low grade, low risk bladder cancer tend to do very well with regular checkups, routine surveillance, occasional installation of chemotherapeutic or biologic agents into the bladder - their prognosis at five years is in the 95% range. For patients with intermediate or high risk tumor who have a five year prognosis, it is lower than that, in the 70% range. Patients who present with high grade bladder cancer who require sysectimay, and even who require addition of either radiation or chemotherapy, do much worse and generally have a prognosis under 50%, in the 40 to 45 percent range.