Bladder Cancer

What is bladder cancer? Bladder cancer is a relatively rare form of cancer that starts in the lining of your bladder. Your bladder is a small hollow organ that holds your pee (urine). Healthcare providers have many ways to treat bladder cancer, including surgery to remove bladder cancer. Bladder cancer may come back after treatment, so people with bladder cancer should be vigilant about following up with their healthcare providers. Healthcare providers can treat early-stage bladder cancer — cancer that’s found and treated before it can spread — but about 75% of early-stage bladder cancers come back.

How does this condition affect my body? Your bladder is a triangle-shaped organ that’s centered between your hip bones, above your urethra and below your kidneys. Pee from your kidneys drains into your bladder, which is lined with tissue called urothelium. Urothelium is made of cells that stretch when your bladder fills with pee and collapses when it’s empty. (Your bladder can hold about 2 cups of pee.) Bladder cancer happens when certain cells in the tissue lining your bladder mutate or change, becoming abnormal cells that multiply and cause tumors in your bladder. Left untreated, bladder cancer may grow through your bladder walls to nearby lymph nodes and then other areas of your body, including your bones, lungs or liver.

What are bladder cancer types? There are three types of bladder cancer. Each type is named for the cells that line the wall of your bladder where the cancer started. Bladder cancer types include: Transitional cell carcinoma: This cancer starts in transitional cells in the inner lining of your bladder wall. About 90% of all bladder cancers are transitional. In this cancer type, abnormal cells spread from the inner lining to other layers deep in your bladder or through your bladder wall into fatty tissues that surround your bladder. This bladder cancer type is also known as urothelial bladder cancer. Squamous cell carcinoma: Squamous cells are thin, flat cells that line the inside of your bladder. This bladder cancer accounts for about 5% of bladder cancers and typically develops in people who’ve had long bouts of bladder inflammation or irritation. Adenocarcinoma: Adenocarcinoma cancers are cancers in the glands that line your organs, including your bladder. This is a very rare type of bladder cancer, accounting for 1% to 2% of all bladder cancers. Small cell carcinoma of the bladder: This extremely rare type of bladder cancer affects about 1,000 people in the U.S. Sarcoma: Rarely, soft tissue sarcomas start in bladder muscle cells. Healthcare providers may also categorize bladder cancer as being noninvasive, non-muscle-invasive or muscle-invasive. Noninvasive: This bladder cancer may be tumors in a small section of tissue or cancer that’s only on or near the surface of your bladder. Non-muscle-invasive: This refers to bladder cancer that’s moved deeper into your bladder but hasn’t spread to muscle. Muscle-invasive: This bladder cancer has grown into bladder wall muscle and may have spread into the fatty layers or tissues on organs outside of your bladder.

How common is bladder cancer?

Bladder cancer is the fourth most common cancer affecting men and people designated male at birth (DMAB). Men and people DMAB are four times more likely to develop bladder cancer than women and people designated female at birth (DFAB). But women and people DFAB who do have bladder cancer typically have advanced forms of the disease because they don’t know about bladder cancer symptoms. According to the Bladder Cancer Advocacy Network, women are less likely to pay attention to blood in their pee (hematuria), the first and most important bladder cancer symptom, because they associate blood in pee with common gynecological issues.

Bladder cancer typically affects people age 55 and older. On average, people are 73 when they’re diagnosed with bladder cancer. Men and people DMAB who are white are two times more likely to develop bladder cancer than men and people DMAB who are Black.

What’s usually the first symptom of bladder cancer?

Blood in your pee (urine) is the most common bladder cancer symptom. That said, simply having blood in your pee isn’t a sure sign of bladder cancer. Other conditions cause this issue, too. But you should contact a healthcare provider whenever you spot blood in your pee. Other bladder cancer symptoms include:

- Visible blood in your pee (hematuria): Healthcare providers can also spot microscopic amounts of blood in pee when they do a urinalysis.

- Pain when you pee (dysuria): This is a burning or stinging sensation that you may feel when you start to pee or after you pee. Men and DMAB may have pain in their penises before or after peeing.

- Needing to pee a lot: Frequent urination means you’re peeing many times during a 24-hour period.

- Having trouble peeing: The flow of your pee may start and stop or the flow may not be as strong as usual.

- Persistent bladder infections: Bladder infections and bladder cancer symptoms have common symptoms. Contact your healthcare provider if you have a bladder infection that doesn’t go away after treatment with antibiotics.

What causes bladder cancer?

Healthcare providers and researchers don’t know exactly why certain bladder cells mutate and become cancerous cells. They’ve identified many different risk factors that may increase your chance of developing bladder cancer, including:

Cigarette smoke: Smoking cigarettes more than doubles your risk of developing bladder cancer. Smoking pipes and cigars and being exposed to second-hand smoke may also increase your risk.

Radiation exposure: Radiation therapy to treat cancer may increase your risk of developing bladder cancer.

Chemotherapy: Certain chemotherapy drugs may increase your risk.

Exposure to certain chemicals: Studies show that people who work with certain chemicals used in dyes, rubber, leather, paint, some textiles and hairdressing supplies may have an increased risk.

Frequent bladder infections: People who have frequent bladder infections, bladder stones or other urinary tract infections may be at an increased risk of squamous cell carcinoma.

Chronic catheter use: People who have a chronic need for a catheter in their bladder may be at risk for squamous cell carcinoma.

How do healthcare providers diagnose bladder cancer?

Healthcare providers do a series of tests to diagnose bladder cancer, including:

Urinalysis: Providers use a variety of tests to analyze your pee. In this case, they may do urinalysis to rule out infection.

Cytology: Providers examine cells under a microscope for signs of cancer.

Cystoscopy: This is the primary test to identify and diagnose bladder cancer. For this test, providers use a pencil-sized lighted tube called a cystoscope to view the inside of your bladder and urethra. They may use a fluorescent dye and a special blue light that makes it easier to see cancer in your bladder. Providers may also take tissue samples while doing cystoscopies.

If urinalysis, cytology and cystoscopy results show you have bladder cancer, healthcare providers then do tests to learn more about the cancer, including:

Transurethral resection of bladder tumor (TURBT): Providers do this procedure to remove bladder tumors for additional tests. TURBT procedures may also be a treatment, removing bladder tumors before the tumors can invade your bladder’s muscle wall. This test is an outpatient procedure done under spinal or general anesthesia.

Magnetic resonance imaging (MRI) test: This imaging test uses a magnet, radio waves and a computer to take detailed images of your bladder.

Computed tomography (CT) scan: Providers may do this test to see if cancer has spread outside of your bladder.

Chest X-ray: This test lets providers check for signs bladder cancer has spread to your lungs.

Bone scan: Like a chest X-ray, bone scans check for signs bladder cancer has spread to your bones.

Healthcare providers then use what they learn about the cancer to stage the disease. Staging cancer helps providers plan treatment and develop a potential prognosis or expected outcome.

Bladder cancer can be either early stage (confined to the lining of your bladder) or invasive (penetrating your bladder wall and possibly spreading to nearby organs or lymph nodes).

The stages range from TA (confined to the internal lining of your bladder) to IV (most invasive). In the earliest stages (TA, T1 or CIS), the cancer is confined to the lining of your bladder or in the connective tissue just below the lining, but hasn’t invaded the main muscle wall of your bladder.

Stages II to IV denote invasive cancer:

- In Stage II, cancer has spread to the muscle wall of your bladder.

- In Stage III, the cancer has spread to the fatty tissue outside of your bladder muscle.

- In Stage IV, the cancer has metastasized (spread) from your bladder to your lymph nodes or to other organs or bones.

A more sophisticated and preferred staging system is TNM, which stands for tumor, node involvement and metastases. In this system:

- Invasive bladder tumors can range from T2 (the tumor spreads to your main muscle wall below the lining) all the way to T4 (it spreads beyond your bladder to nearby organs or your pelvic side wall).

- Lymph node involvement ranges from N0 (no cancer in lymph nodes) to N3 (cancer in many lymph nodes, or in one or more bulky lymph nodes larger than 5 centimeters).

- M0 means that there isn’t any metastasis (spread) outside of your pelvis. M1 means that it has metastasized outside of your pelvis.

How do healthcare providers treat bladder cancer?

There are four types of bladder cancer treatment. Providers may use any or all of these treatments and may combine treatments.

Surgery

Surgery is a common bladder cancer treatment. Providers chose surgical options based on the cancer stage. For example, many times, TURBT, the procedure used to diagnose bladder cancer, can treat bladder cancer that hasn’t spread. Healthcare providers either remove the tumor or use high-energy electricity to burn it away with a process known as fulguration.

Radical cystectomy is another treatment option. This surgery removes your bladder and surrounding organs. It’s done when people have cancer that’s spread outside of their bladder or there are several early-stage tumors throughout their bladder.

In men and people DMAB, this surgery removes prostates and seminal vesicles. In women and people DFMB, providers may remove ovaries, their uterus and part of their vagina. Providers also do surgery known as urinary diversion so people can still pass pee.

Providers may follow surgery with chemotherapy or radiation therapy to kill any cancer cells surgery may have missed. This is adjuvant therapy.

Chemotherapy

These are cancer-killing drugs. Providers may use intravesical therapy to deliver chemotherapy drugs directly to your bladder via a tube inserted into your urethra. Intravesical therapy targets cancer without damaging healthy tissue.

Immunotherapy

Immunotherapy is a treatment that uses your immune system to attack cancer cells. There are different types of immunotherapy:

Bacillus Calmette-Guérin (BCG): This is a vaccine that helps boost your immune system.

PD-1 and PD-L1 inhibitor therapy: PD-1 and PD-L1 are proteins found on certain cells. PD-1 is on the surface of T-cells that help regulate your body’s immune responses. PD-L1 is a protein found on the surface of some cancer cells. When these two proteins connect, the connection keeps T-cells from killing cancer cells. In inhibitor therapy, the two proteins can’t connect, leaving the way clear for T-cells to kill cancer cells.

Radiation therapy

Radiation therapy may be an alternative to surgery. Healthcare providers may combine radiation therapy with TURBT and chemotherapy. This treatment is an alternative to bladder removal surgery. Healthcare providers consider factors such as tumor growth and tumor characteristics before recommending this treatment

Targeted therapy

Targeted therapy focuses on the genetic changes that turn healthy cells into cancer cells. For example, drugs called FGFR gene inhibitors target cells with gene changes that help cancer cells grow.