Bladder Cancer
Bladder Cancer
You may have heard it from physicians, from family members who
have been doing their reading, or from spinal cord injury survivors
who go to other doctors or who were treated at different hospitals
or rehabilitation centers: “You’re going to develop cancer of
the bladder if you keep that catheter in.” Are they right? No
one knows. Is the risk of bladder cancer higher in spinal cord
injury survivors? Yes. Is it further increased by using an indwelling
catheter? Again, yes. Is the risk unreasonable? Only you can make
that decision. Are there things you can do to reduce that risk?
Probably. The key lies in knowing your own risks, understanding
your choices, and making the necessary tradeoffs, based on solid
information.
Three Pieces to the Puzzle:
There are three different pieces to the bladder cancer puzzle.
All of them are important for understanding the big picture. First,
there is incidence. Just how much more common is bladder cancer
among spinal cord injury survivors? How great are the chances
of developing it? Second, there are risk factors. What are some
of the things that increaseand decrease the risk for bladder
cancer? Finally, there is you. What can you do to change, lessen,
or just understand those risks. It’s a complicated picture; if
you still have questions after reading this, get more information.
Incidence:
The truth is that bladder cancer is more common than in the general
population. However, in reality, it’s a very rare disease in nondisabled
people that becomes somewhat more common among SCI survivors.
In the general population, the incidence of bladder cancer is
about 1 person in every 5000.1 That’s less than 1%; less even than 1/10th of 1%. In spinal cord injury, the most commonly quoted overall incidence
seems to be around 150 in every 5000, or 3%. This is an average,
based on the findings of many different studies. Some studies
showed lower cancer rates. For example, a 1991 study of 2900 spinal cord injury
survivors at three US hospitals found eight cases (less than 1%)
of bladder cancer;1 in an earlier study at Stoke Mandeville Hospital in England,
there were 25 cases in 6744 persons (4%);2 and out of 1052 new admissions at a veterans hospital in Virginia,
ten diagnoses of bladder cancer (1%) were found.3 Finally, at Craig Hospital, when the records of 2660 former patients
with SCIs were examined, 13 cases of bladder cancer were identified
(less than 1%).
So, just for some perspective: even though bladder cancer may
be 100 times more frequent in SCI survivors than in the general
population, it still isn’t extremely common. A non-disabled woman's
chance of developing breast cancer is greater1 in 8than an SCI
individual has of developing bladder cancer. And, within SCI itself,
complications like pressure sores, spinal cord cysts, hyperreflexia,
and kidney failure are much more common, while illnesses like
heart disease and respiratory complications account for far more
deaths.4
Risk Factors:
There’s more to know: indwelling cathetersurethral catheters,
“foleys,” suprapubic
cystostomies, “super-tubes”do tend to bear the blame for this
increased risk. However, that may be an over simplification of
the problem.
In fact, it seems likely that several different factors interact
to increase the bladder cancer risk for SCI survivors. Indeed,
even catheter-free survivors, or those who use intermittent catheterization,
have higher bladder cancer rates than the general population.2,5
Bladder Irritation is the key: Most of the factors increasing this risk for bladder cancer relate
to one thing: irritation of the bladderboth chronic and repeated.
Many scientists and researchers suspect that spinal cord injury,
because of the way it changes the urinary system and alters the
environment inside the bladder, may increase the amount and types
of irritation the bladder is subject to.
One big irritant is urinary tract infections; the more frequent
and more severe they are, the more irritation they may cause.
And, they seem to play a role regardless of whether there's a
catheter present. In addition to the irritation they cause, some
researchers suspect that urinary tract infections cause the release
of a substance in the bladder, called nitrosamine.2,6 This substance,
itself, may enhance the development of cancerin much the same
way that cigarette smoke may enhance cancer formation in the lungs.
Indeed, the effects of bladder infections and nitrosamines may
partly explain why people who don’t use catheterswhether able-bodied
or SCI survivorssometimes get bladder cancer, too.7
Bladder stones are also potential irritants.6,8,9. Stones have been studied less than urinary tract infections,
but their role seems obvious. First, they’re believed to occur
because of some irritationa stray hair, grit, sediment already
present in the bladder. Second, when not removed, bladder stones
become a source of irritation, causing mechanical or physical
irritation within the bladder and fostering urinary tract
infections, which themselves cause irritation.
Smoking may be another form of irritation, and smokers do face
an increased risk of bladder cancer.6,7 Are spinal cord injured smokers at even greater risk? Possibly.
Carcinogens, like those found in cigarette smoke, may be carried
in the urine. One researcher found evidence to suggest that the
presence of urinary tract infectionswhich many SCI survivors
havemay make the bladder even more susceptible to these carcinogens.6
The catheter’s role: Still, without a doubt, the catheter itself is the largest potential
source of irritation. In some people, tumors have been seen inside
the bladder where the catheter rubs, and in the path where the
catheter lays.5,10 The incidence of cancer is still much higher among those who
do have indwelling catheters than among those who use external
collectors, intermittent catheter-ization, credé, and most other
types of bladder management. In the Craig Hospital study of 2660
SCI survivors, indwelling catheters were found to increase the
risk of cancer 3.8 times, compared with SCI survivors who did
not use indwelling catheters.
The biggest catheter-related risk factor seems to be how long
the catheter has been in place. Some researchers have reported
that cancer rates go up the longer people use indwelling catheters.9,11 In the Craig study, the cancer risk in the 2660 people studied
was only 0.2% during the first 10 years. But, by 30 years, in
a group that was relatively small in size, the risk of bladder
cancer had risen to 9% for indwelling catheter users.
Another catheter-related risk that has been suggested is a factor
called the “era of care.” Some physicians believe that people
most at risk are those who were injured long agobefore modern
antibiotics, anticholinergic drugs, and catheters made from safer,
non-rubber materials, were available. Some even believe that bladder
cancer incidence rates will be lower among more recently injured
SCI survivors who are treated with today’s more modern methods.
Diagnosing Bladder Cancer:
The most common symptom of bladder cancer is blood in the urine:
blood that is
chronic or recurring and that does not appear to be related to
a urinary tract infection. However, because many other thingsless
serious than cancercan cause blood to appear in the urine, the
best way to monitor the bladder is by having a urologist examine
it.
With an instrument called a cystoscope, the urologist can see
inside the bladder. If any suspicious areas are noted, he or she
may recommend a biopsya procedure in which a small piece of the
bladder wall is scraped away and examined carefully under a microscope.
Though biopsies may cause some blood-tinged urine for a day or
two, they’re not usually painful and can be done fairly simply
at the same time as the cystoscopy itself.
Biopsies: It’s fairly common for the biopsy report to come back with a
diagnosis of squamous metaplasia. This is a medical term for a
microscopic cellular change that is often seen in the bladder.
Some scientists believe that microscopic squamous metaplasia is
a warning sign of a particular kind of bladder cancersquamous
cell carcinoma.11 Both squamous metaplasia and squamous cell carcinoma are believed
to result from those already-described chronic irritations inside
the bladderstones, UTIs, catheters. Therefore, these scientists
argue, both of these conditions should be of concern to SCI survivors,
especially those who manage their bladders with indwelling catheters.
However, the truth is, researchers do not agree on this issue.
Many others argue that
while squamous metaplasia may be a precursor to cancer it is not
always something to worry about.
Why the controversy? Several reasons. Squamous metaplasia is extremely
common
among both nondisabled people and spinal cord injury survivors.3,12 Many people have squamous metaplasia and never develop bladder
cancer. In one study of 450 non-disabled people who already had
squamous metaplasia, none developed squamous cell cancer!12
Among SCI survivors, as many as 80% of catheter users may have
squamous metaplasia,8 and common sense dictates that not all are going to develop bladder
cancer. In another Craig Hospital study, for example, 172 spinal
cord injury survivors had bladder biopsies. All of them had indwelling
catheters most were suprapubics. More than half of the 172 people
who were tested did have squamous metaplasia. None of them were
found to have squamous cell carcinoma.
Interpreting Risk:
What does all this mean? Before we talk about what you can do
to minimize your risk for bladder cancer, let’s sift through what’s
been said so far:
- As a spinal cord injury survivor, the risk of developing bladder
cancer is higher than if
you had not been spinal cord injured. With an incidence of about
3% among all SCI
survivors, it's not astronomical, but it is measurable.
- The risk of developing cancer is increased further if you use
an indwelling catheter. This is probably because of physical or
mechanical irritationby catheters rubbing inside the bladder
as well as chemical irritation caused by frequent bladder infections.
And, it seems the longer the catheter is in, the more the risk
goes up.
- Smoking is believed to increase your risk of developing bladder
cancer.
- Biopsies are very important for early diagnosis of bladder cancer,
but the significance of squamous metaplasia as a warning sign
is extremely controversial. However, it probably is safe to conclude
that not having squamous metaplasia is better than having it.
Decreasing Risk:
Regardless of whether you are catheter-free or use an indwelling
catheter, probably the best advice is to be meticulous in all
aspects of your bladder management program. Follow all physician
recommendations about medications, fluid intake, cleanliness,
monitoring, and follow-up. Most important, stay up-to-date. Ongoing
research may make new information available that could be beneficial
to you.
If you do happen to have an indwelling catheter, here are some specific
things you can do to reduce your risk:
Decrease the amount of irritation in your bladder:
- If anticholinergic drugs were prescribed, use them. These drugsDitropan,
Oxybutinin, Dariconrelax the bladder, and as a result, decrease
the amount of irritation it is subject to.
- Each day, switch the leg that you put your drainage bag on. If,
because of functional reasons, you can’t do this, then try putting
your night bag on the opposite side of your body as your daytime
leg bag. This, in theory, should move the catheter tube and its
balloon within your bladder so the same spot on your bladder wall
doesn't have all the irritation.
- Use the newer, less irritating hydrophilic catheters. They're
lubricated and made of softer materials which makes them less
irritating. But, regardless of which type you use, change it as
often as recommended. This is not the place to try to save money!
- Get yourself checked regularly for stones. Repeated bladder infections
and grit in your urine are some possible signs that you might
have stones. If your urologist does find bladder stones, have
them removed.
- If you have concerns about indwelling catheters, the irritation
they cause, and bladder cancer, you may want to consider the tradeoffslike
convenience and familiarityof
shifting to a catheter-free bladder management program. However,
keep in mind that we just don't know how much a change in your
program will decrease your risk. Will your bladder return to "normal"?
Probably not. Will future, continued bladder irritation be lessened?
Probably. Talk it over with your doctor.
Prevent infections & stones:
- Drink lots of water. Drink enough so that you put out 3 to 4 quarts
of urine a day. Everyone’s body uses different amounts of water
at different times, so don’t assume that taking in 3 to 4 quarts
will guarantee that you'll put out that much; it may take more.
- If, because of your own bladder history, your physician recommends
that you take maintenance doses of medications to suppress bacterial
growth, do it.
- If you feel like you're having a lot of bladder infections, work
with your doctor to try to identifyand eliminatethe cause. Two
or three urinary tract infections a year is probably typical of
most SCI survivors; a lot more is a problem, not only because
of the possible bladder cancer risk, but because of the impact
on your genitourinary system and on your health in general.
- Maintain personal cleanliness to prevent your exposure to infection-causing
bacteria. Be meticulous in your catheter-changing technique. If
you have a suprapubic catheter, keep the site around the catheter
shaved and clean. Use chlorine bleach and water to keep your leg
bags, night bags, and tubing clean and bacteria-free.
Decrease your exposure to cancer-causing agents in general:
- Don’t smoke. If you do smoke, quit now.
- Learn more about antioxidant vitamins. These include Vitamin C,
Vitamin B6 and Vitamin E and other vitamins. Magazine and television
reports tell us they may reduce the effects of cancer-causing
agents in the body. Some preliminary research seems to show that
antioxidants may reduce recurrences in people who already have
bladder cancer.13 Although, in theory, this suggests some possible role for antioxidants
in the prevention of bladder cancer, this has yet to be proven.
If you’re considering taking theseor any other vitaminsin more
than their recommended dosages, talk with your physician.
- Remember, infected urine may contain substances that increase
cancer risk. Call your doctor about any symptomatic bladder infections
you have. Symptoms include fever and chills, cloudy, smelly urine,
drainage around the catheter, unexplained autonomic hyperreflexia,
and pinkish or bloody urine. Don't ignore bloody urine; it can
be a warning sign.
- If you have an indwelling catheter of any kind, follow the cystoscopy
schedule recommended by your urologist or SCI physician, as these
exams can be a means of early detection. If you've had your indwelling
catheter for more than 10 years, you probably won't want to go
more than a year or two between cystoscopies. And, based on your
"cysto" results, your doctor can then tell you if a biopsy is
useful or indicated.
You can't undo your spinal cord injury, but taking these steps
will help minimize your risk for bladder cancer. To come back
to the big question: Should you abandon your indwelling catheter
program for one that is less invasive? There's no easy answer.
If everything else is equal and your bladder could work just as
well without an indwelling catheter, and if your independence
and quality of life would not be affected by the program you chose,
it probably would be safer to go with a program that does not
involve an indwelling catheter. But, it's seldom that simple.
The key questions to ask yourself are:
- How many years have I used an indwelling catheter? Is there a
point at which the increasing cancer risk outweighs the catheter's
convenience and independence?
- Can another type of bladder management decrease the infections
and other complications I have? Can that method work for me? Can
I accept any decrease in convenience or independence that might
be part of a new bladder program?
- What method allows me to lead the kind of life I want to leadand
need to leadnow?
Answering these questions is difficult and complicated. Get the
information you need about your own unique situation so you can
weigh the tradeoffs. Research, your doctor, your family and friends,
and other SCI survivors can help you, but only you can make the
final decision.
References for this article:
1 Bickel A, Culkin DJ, Wheeler JS (1991). Bladder cancer in spinal
cord injury patients The Journal of Urology146:1240-2.
2 El Masri WS, Fellows G (1981) Bladder cancer after spinal cord
injury. Paraplegia 19:265-70.
3 Broecker BH, Klein FA, Hackler RH (1981). Cancer of the bladder
in spinal cord injury patients. The Journal of Urology 125:196-7.
4 Whiteneck GG (1993). Learning from recent empirical investigations.
Aging with Spinal Cord Injury. NY: Demos
5 Sene AP, Massey JA, McMahon RTF, Carroll RNP (1990) Squamous
cell carcinoma in a patient on clean intermittent self-catheterisation.
British Journal of Urology 65(2):213-4.
6 Dolin PJ, Darby SC, Beral V (1994) Paraplegia and squamous cell
carcinoma of the bladder in young women: findings from a case-control
study. British Journal of Cancer 90:167-8.
7 Kantor AF, Hartge P, Hoover RN, Narayana AS, Sullivan JW, Fraumeni
JF (1984). Urinary tract infections and risk of bladder cancer.
American Journal of Epidemiology 11:510-5.
8 Locke JR, Hill DE, Walzer Y (1985). Incidence of squamous cell
carcinoma in patients with long-term catheter drainage. The Journal of Urology 133:1034-5.
9 Kaufman JM, Fam B, Jacobs SJ, Gabilondo F, Yalla S, Kane JP,
Rossier AB (1977). Bladder cancer and squamous meta-plasia in
spinal cord injury patients. The Journal of Urology 9(3):317-20.
10 Kaye MC, Levin HS, Montague DK, Pontes JE. (1992) Squamous
cell carcinoma of the bladder in a patient on intermittent self-catheterization
Cleveland Clinical Journal of Medicine 59(6):645-6.
11 Esrig D, McEvoy K, Bennett CJ (1992). Bladder cancer in the
spinal cord-injured patient with long-term catheterization: a
casual relationship Seminars in Urology10(2):102-8.
12 Widran J, Sanchez R, Grunn J (1974). Squamous metaplasia of
the bladder: a study of 450 patients. The Journal of Urology 112:479.
13 Lamm DL, Riggs DR, Shriver JS, vanGilder PF, Rach JF, DeHaven
JI (1994). Megadose vitamins in bladder cancer: a double-blind
clinical trial. Journal of Urology. 51:21-6.
This is one of more than 20 educational brochures developed by
Craig Hospital while it was a federally-funded Rehabilitation
Research & Training Center on Aging with Spinal Cord Injury. The
opinions expressed here are not necessarily those of the funding
agency, the National Institute on Disability and Rehabilitation
Research of the US Department of Education.
For a hard copy of a METS brochure, click on your selection above
and hit the "print" button on your browser.If you'd like to ask for one directly from Craig Hospital, you can contact us by telephone at 303-789-8202, or you can e-mail us at HealthResources@craighospital.org.
|
