Bladder Cancer

Written by Dr harold Gunatillake FRCS, Health writer to e-Magazines, websites, Sri Lankan newspapers and expatriate tabloids

The function of the bladder is to store urine filtered from the kidneys entering through two tubes called ureters, and to void when the urge signals to empty. It can be compared to a low pressure reservoir which stretches out as urine fills into it.

It lies in the pelvic basin, well protected by the pelvic bones at times of a major accident.

The bladder is composed of three layers. The innermost layer forms the mucosa and consists of several layers of specialized cells called "transitional cells" which are almost exclusively found in the urinary system including the kidneys, ureters and the bladder. The middle layer is a thin lining known as the "lamina propria" and forms the boundary between the inner mucosa and the outer muscular layer. Outside these three layers is a variable amount of fat which protects the bladder like in most other organs and also has a cushioning effect.

Incidence
Cancer of the urinary bladder develops in over 70,000 Americans each year, leading to over 14,000 deaths. According to the American Cancer Society, the chance of a man developing this cancer at any time during his life is about one in 30; for a woman, the chance is one in 90. Since bladder cancer that is detected in the early stages has a good chance of cure, awareness of the signs and symptoms of this malignancy are critical. Anyone experiencing the signs or symptoms of bladder cancer should be checked by an urologist, who can perform tests to diagnose bladder cancer even in its early stages.

In Sri Lanka no published data exists on bladder cancer. 301 patients were diagnosed with primary bladder cancer during a 7.5 year period from 1993 to 2000.
Two hundred and eighty-one patients (239 men and 42 women; mean age, 66 years; range, 26-88) with transitional cancer of the bladder were evaluated with regard to clinical presentation, cystoscopy findings and histopathological data. (Int. J. Urol. 2004 Nov, 11 Goonewardena SA and De Silva WA and MV)

Bladder Cancer
Bladder cancer may remain within the mucosa composed of transitional layers of cells, or may invade into the deeper layers as it grows.

95% of cancers are urothelial cancers, previously labeled as "transitional cell cancer". It is strongly associated with cigarette smoking. The toxic chemicals in the cigarette smoke travels in the blood stream after being absorbed in the lungs and get filtered into the urine in the kidneys. Contamination of the urine with highly toxic chemicals like hydrocyanic acid, is prone to irritate and cause multiplication of the cells in the mucosal lining and cause the cancer. It is a lucky cancer, in the sense they remain local, may spread locally and remain within the mucosa alone. Recurrence is very low if all the cancerous growths are exterminated by surgery or otherwise.

Transitional cell cancer accounted for 93.4% of primary bladder cancer in Sri Lanka during the period mentioned.
Such early detected un-spread cancers of the bladder wall, can usually be removed by an outpatient surgical procedure through cystoscopy

If a tumor has grown into the wall of the bladder but has not spread to other organs, treatment usually involves surgical removal of the tumor, or combined chemotherapy and radiation therapy, with a five-year survival rate of 60%-75%. In more advanced cases, with spread of the cancer to other sites in the body, more aggressive treatment plans must be considered.

Adenocarcinoma forms about 2% is associated with prolonged infection, inflammation, and irritation associated with stones in the bladder. The commonest infection associated with bladder cancer is caused by a worm named Schistosoma, also called bilharzia.

Other rare forms include small cell cancer and pheochromocytoma and sarcoma.

Bladder cancers could be uncontrollable

Most bladder cancers are detected in people over 69 years. Mostly, men are affected due to the high incidence of smoking and exposure to toxic chemicals. Cigarettes are made up of tobacco, nicotine, tar, arsenic, and acetone. Combustion of a cigarette involves the formation of many toxic chemicals including more than forty that are cancer producing.

Lighting a cigarette produces hydrocyanic acid, nitric oxide, ammonia and mercury.

Hydrocyanic acid in the inhaled smoke is considered carcinogenic to the inner lining (mucosa) of the ureter and the bladder, referred to as transitional cell cancer.

Other chemicals causing cancer are phenols, aniline dyes, arsenic and arylamine. Dye workers, rubber workers, aluminum workers, leather workers and truck drivers and pesticide applicators are also at the highest risk.

Exposure to certain chemicals used in manufacturing and industry like paint, thinners, some hair dressing supplies, are associated with bladder cancer.

Radiation therapy to the prostate and cervical cancers in women and chemotherapy with cyclophosphamide has been shown to risk development of bladder cancer.

Symptoms and signs
Painless bleeding in the urine would be the earliest visible symptom of bladder cancer. Occasionally, the person may be not able to pass urine due to blood clots in the urethral passage. Sometimes there is only burning sensation whilst passing urine with no bleeding. This is commoner in cancers where infection happens to be a cause.

Diagnosis
Urinalysis
Blood cells in the urine, macroscopic or microscopic indicate an infection or other causes of bleeding like stones and early growth. Ladies should wait till the menses is over for a few days before urinalysis.

Urine cytology
This will reveal abnormal and malformed cancer cells under the microscope.

Ultrasound
This test can show the presence of swelling in the kidneys, stones, bladder tumors, and prostate enlargement and so on. A very essential test

Cystoscopy and biopsy
This procedure is normally done by an urologist most probably under anesthesia in an operating room.

Grading
In 2004, the World Health Organization developed a new grading system for bladder cancer. This system divides bladder cancers into the following groups.
· Urothelial papilloma - noncancerous (benign) tumor
Papillary urothelial neoplasm of low malignant potential (PUNLMP) - slow growing and unlikely to spread
· Low-grade papillary urothelial carcinoma - slow growing and unlikely to spread
· High-grade papillary urothelial carcinoma - more quickly growing and more likely to spread


Conservative Management
Chinese herbal medicine
Chinese herbalists believe that without participation of herbal medicine, a treatment can rarely be said a complete one. They believe that herbs seem to always a good assistant to conventional treatments. The main ingredient in Chinese medicine is an herb called Herba Sarcandrae, believed to kill cancer cells. Speak no more about this herb. Those who believe in these herbs may find themselves in most unscientific hands.

Wonder drug Vitamin B17
Apricot seed kernel and our home grown manioc are supposed to have a chemical called Amagadolin- labeled as Vitamin B17. The theory goes that cancer cells have different enzymes to normal cells. These enzymes are broken down with B17 to 1 sugar, 1 Benz aldehyde, and 1 hydrocyanic acid. The hydrocyanic acid is supposed to kill cancer cells through enzymatic activity.

There is a problem accepting this theory. Hydrocyanic acid in tobacco cause superficial cancer called 'Transitional cell cancer' (described above), in the ureter and bladder.

Hydrocyanic acid produced from enzymatic activity on Vitamin B17, found in manioc and apricot seed kernel is supposed to kill those very cancer cells originated due to irritation from Hydrocyanic acid with tobacco smoking.
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