This information has been prepared to help you understand more about bladder cancer.
Many people feel understandably shocked and upset when they are told they have bladder cancer. This information is intended to help you understand the diagnosis and treatment of bladder cancer.
We cannot advise you about the best treatment for you. You need to discuss this with your doctors. However, we hope this information will answer some of your questions and help you think about the questions you want to ask your doctors or other health carers.
The bladder is a hollow, muscular, balloon-like organ that stores urine. It sits in the lower part of the abdomen.
The bladder is made up of three main tissue types:
- The innermost layer is the mucous membrane (mucosa or urothelium). Cells in this membrane are called urothelial cells and stop urine going into the body.
- Surrounding the mucous membrane is strong tissue known as the lamina propria.
- The outermost layers are thick, protective muscle tissue, which is covered by a layer of fat.
The kidneys produce urine, which is carried to the bladder by tubes called ureters. When the bladder is emptied, urine passes through a tube called the urethra and out of the body.
In women, the urethra is a very short tube and opens in front of the vagina (birth canal).
In men, the tube is longer and passes through the prostate and down the penis.
What is bladder cancer?
Bladder cancer occurs when cells in the bladder become abnormal and grow uncontrollably. The cancer can spread through the bladder and into other parts of the body.
Nearly all bladder cancers begin in the innermost layer of the bladder (mucous membrane). In some cases, the cancer may progress by growing into the deeper layers of the bladder wall.
Bladder cancers can be divided into two categories:
- Non-invasive tumours (superficial tumours): the cancer is only found in the lining of the bladder and has not invaded deeper layers. This does not necessarily mean the cancer is not serious. One type of non-invasive cancer is carcinoma in-situ.
- Invasive tumours: the cancer has spread beyond the lining of the bladder, either into the lamina propria, the muscle, or through the bladder wall. All invasive tumours are serious.
Types of bladder cancer
The three main types of cancers affecting the bladder are:
Urothelial carcinoma (or transitional cell carcinomas) – makes up about 90% of all bladder cancers and arises from the innermost tissue layer. Urothelial cancers are mostly non-invasive and are further categorised according to their shape and how invasive they are. Sub-types include papillary urothelial carcinomas and flat urothelial carcinomas.
Squamous cell carcinoma – makes up about 8% of all bladder cancers. This type of cancer starts in the flat cells that line the bladder and is more likely to be invasive.
Adenocarcinoma – the rarest type of bladder cancer, accounting for 1-2% of all cases. The cancer develops from the cells that produce mucus and is likely to be invasive.
How common is it?
If you would like to read any facts or statistics about bladder cancer, please refer to the Cancer Institute NSW website:
What is the cause?
The exact causes of bladder cancer are not known, however some factors will increase your risk:
- smoking – cigarette smokers are about six times more likely to develop bladder cancer
- industrial exposure – chemicals called aromatic amines and aniline dyes have been linked to bladder cancer
- chronic infections – infections (including parasite infections) and untreated bladder stones have been linked with squamous cell carcinoma
- long-term catheter use – squamous cell carcinoma may be associated with long-term urinary catheter use
- previous cancer treatments – including the drug cyclophosphamide and radiotherapy to the pelvic area
- diabetes – people with diabetes are more likely to develop bladder cancer
- personal or family history – rarely, bladder cancer is associated with an inherited faulty gene
- gender – men in NSW are approximately four times more likely than females to be diagnosed with bladder cancer
What are the symptoms?
Occasionally, bladder cancer doesn’t have many symptoms and is found during routine urine tests. When symptoms do occur, blood in the urine (haematuria) is the most common. This can occur suddenly and is generally not painful. Sometimes there is only a small amount of blood, which can be red or brown in colour and appears intermittently (it may appear and disappear from one day to the next or only appear once or twice). Sometimes blood clots may form, which can cause problems when emptying the bladder.
Seeing blood in your urine may not mean that you have bladder cancer – it is also a symptom of other conditions, such as kidney or bladder stones, and non-cancerous enlargement of the prostate in men. However, if you notice blood in your urine it is important to discuss it with your doctor.
Other symptoms of bladder cancer include:
- a burning feeling when passing urine
- the need to pass urine more often or urgently
- not being able to urinate when you feel the urge
- pain during urination
- pain in the lower abdomen or back
Your doctor will often do a number of tests before they diagnose bladder cancer. Most bladder cancers have a low chance of spreading – particularly if found early – so some tests may not be necessary.
Simple procedures that can give an indication of whether or not cancer is present. General tests include:
A physical examination may be conducted to determine the size of your bladder tumour and whether it has spread. Your doctor will feel for anything unusual by inserting a gloved finger into the rectum in males or the vagina in females.
A blood test will show whether different types of blood cells are normal in number and/or appearance. It can also show how well your organs are working.
A urine sample is obtained and sent to a laboratory. The laboratory tests the sample for blood, bacterial infection (not cancer) or cancerous cells in the urine.
Additional tests may be conducted to find the position of the cancer and work out whether it has spread.
Tests to find the position of the cancer include:
Cystoscopy and biopsy
Cystoscopy is the main procedure used to diagnose bladder cancer. It is a surgical procedure that is usually done as day surgery under local or general anaesthetic. If the doctor needs to take a tissue sample (biopsy), you will usually be given a general anesthetic.
A thin tube (cystoscope) is inserted through your urethra into the bladder. The cystoscope has a lens and a light that allows the doctor to view the bladder on a monitor. Small pieces of tissue can be removed from suspicious areas and examined under a microscope. If cancer is found during the cystoscopy, it may be removed during the procedure.
An ultrasound uses soundwaves to make a picture of your organs. A gel is spread on the abdomen, and a small device called a transducer is moved over the area. It sends out soundwaves that echo when they meet something dense like an organ or tumour. A computer creates a picture from these echoes.
Ultrasound scans are used to show if cancer is present and how large it is. It may miss small tumours.
Tests to find any cancer that may have spread include:
A CT scan is a type of X-ray that takes several pictures that can be put together to build up a three-dimensional picture of your body. A CT scan is used to diagnose cancer and show if it has spread. The scan may be called a three-phase renal CT or a CT IVP (intravenous pyelogram).
Before the scan, a dye is injected into your vein. You may feel hot and flushed, with some discomfort in your abdomen for a short time. The dye then travels through your bloodsteam to the kidneys, ureters and bladder so that these organs are shown clearly on the X-rays.
You will be asked to lie still while you pass through the CT scanner.
An MRI scan uses magnetic waves to create detailed cross-sectional pictures of organs in your abdomen. You may be injected with a dye that highlights your organs. The pictures produced during the scan show the difference between normal and diseased tissue.
Radioisotope bone scans
A radioisotope scan may be done to see if any cancer cells have spread into the bones. A small amount of radioactive liquid is injected into a vein, usually in your arm. The radioactive substance will collect in areas of abnormal bone growth. A scanner measures the radioactivity levels and records them on X-ray film. This may take a couple of hours after the dye has been injected.
Due to the fact that a radioactive liquid is used, it is important to avoid contact with pregnant women and young children for the rest of the day.
A chest X-ray is sometimes done at the same time as a CT scan and is used to check your lungs for signs of cancer.
Staging and grading bladder cancer
Staging and grading your bladder cancer can help your health care team work out what treatment is best and what your prognosis (or expected outcome) is.
Staging tells the doctor how far the cancer has spread.
The most common staging system used for bladder cancer is known as the TNM system:
T (Tumour) 1-4: indicates the size and depth of the tumour invasion into the bladder and nearby tissues. The higher the number, the more likely the cancer has spread beyond the bladder.
N (Nodes) 0-3: indicates whether cancer has spread to nearby lymph nodes. No nodes affected is 0; increasing node involvement is 1, 2, or 3.
M (Metastasis) 0-1: indicates whether the cancer has (1) or hasn’t (0) spread, or metastasised, to other parts of the body.
The stage can also be described using numbers:
Stage 0a – there is a small area of cancer in the bladder lining that has not spread.
Stage 0 is (carcinoma in-situ) – a flat tumour confined to the lining of the bladder, which is almost always high grade.
Stage 1 – the cancer has spread into the connective tissue.
Stage 2 – the cancer is in the muscle of the bladder wall, under the connective tissue.
Stage 3 – the cancer has grown through the layer of muscle in the bladder and into surrounding fat. It may have spread to nearby organs, such as the prostate or vagina.
Stage 4 – the cancer has spread throughout the body to the walls of the abdomen or pelvis, lymph nodes, bones and other organs.
Grading describes how fast cancer cells are likely to grow. There are two main grades of bladder cancer:
Low-grade: The cancer cells look fairly normal and behave similarly to healthy cells. The cells tend to grow slowly. Most bladder tumours are low grade.
High-grade: The cancer cells look very abnormal and grow in a disorderly way. These cells tend to grow very quickly.
Prognosis means the expected outcome of a disease.
Bladder cancer can be effectively treated if it is found early, before it spreads outside the bladder.
You can discuss your prognosis with your doctor, but it is not possible for anyone to give you an accurate prediction on the course of your illness. The rate and growth of the cancer, your treatments and how well you respond to them, and other factors such as age and medical history are all important factors in assessing your prognosis.
Which health professionals will I see?
If these tests do not rule out cancer, your GP will refer you to a urologist, who will examine you and may do more tests.
The following list includes a range of health professionals that you may see throughout your treatment and recovery. Depending on the type and stage of your cancer you may not see all of these health professionals. For example, most people with non-invasive bladder cancer do not need radiotherapy or systemic chemotherapy so they will not see a medical oncologist or radiation oncologist.
- General practitioner – a doctor who arranges the first tests to check out your symptoms.
- Urologist – a surgeon who specialises in diseases of the urinary system and the male reproductive system.
- Medical oncologist – prescribes and coordinates the course of chemotherapy.
- Radiation oncologist – prescribes and coordinates the course of radiotherapy.
- Nurses – support and assist you through all stages of your cancer.
- Stomal therapy nurse – provide assistance and support to patients with a stoma.
- Continence nurses – assess and educate patients about continence care.
- Dietitian – recommends the best eating plan to follow during and after treatment.
- Social worker, physiotherapist and occupational therapist – link you to support services and help you get back to normal activities.
Non-invasive bladder cancer
If you have non-invasive bladder cancer you will probably undergo surgery, either alone or in combination with other treatments.
The most common type of surgery for people with non-invasive bladder cancer is a transurethral resection of bladder tumour (TURBT). This is done under a general anaesthetic. A cystoscope (a thin tube with a light and lens) is passed through the urethra into the bladder. The cystoscope has a wire loop or laser which allows the doctor to remove the tumour through the urethra.
The surgeon may also use other techniques to kill the cancer cells. The cystocope may be used to burn the base of the tumour (fulguration). A high-energy laser can also be used to damage or kill the cancer cells.
Immunotherapy for non-invasive bladder cancer
Immunotherapy encourages the body’s own natural defences (immune system) to fight disease. It is the main way of treating carcinoma in-situ (CIS), and can also be used to treat invasive cancer that has grown into the lamina propria.
The most effective type of immunotherapy for treating non-invasive bladder cancers is Bacillus Calmette-Guérin (BCG). It is usually given 2-4 weeks after TURBT surgery, as six weekly treatments. BCG is administered directly into the bladder through a flexible tube called a catheter. You may be asked to change position every 15-20 minutes so that the vaccine can wash over the entire bladder.
Some people may also have long-term BCG therapy (known as maintenance treatment). Maintenance treatment usually involves three treatments over a six-month period, for up to two years.
Intravesical chemotherapy for non-invasive bladderCancer
Chemotherapy is the treatment of cancer with anti-cancer drugs. The drugs work by killing cancer cells or slowing their growth.
In intravesical chemotherapy the drugs are put directly into the bladder using a flexible tube called a catheter. This is called an installation. You may have one installation at the time of surgery, or weekly installations over about six weeks. During this time, your doctor may advise you to use contraception.
An advantage of intravesical chemotherapy is that the drugs stay in the bladder and do not usually spread throughout the body. This limits the unwanted side effects that can occur when chemotherapy is given orally or intravenously (via the veins).
Invasive bladder cancer
Invasive bladder cancer is most commonly treated with surgery. In some cases, surgery may be used with chemotherapy, or both radiotherapy and chemotherapy. If you don’t have surgery, you will probably have a combination of radiotherapy and chemotherapy.
If you have muscle-invasive bladder cancer or cancer that has invaded the lamina propria but has not responded to BCG you will probably undergo surgery. There are many surgical options depending on the stage of your cancer, including:
This procedure involves the removal of the whole bladder, nearby lymph nodes and, in most cases, the appendix. It is the most common operation for invasive bladder cancer. Men with bladder cancer will often also have their prostate, urethra and seminal vesicles removed. Similarly, women may have additional organs removed including the uterus, ovaries, a small portion of the vagina, and fallopian tubes.
After a radical cystectomy, a new bladder will be created to store and remove urine. This can be done in several ways depending on your medical situation and personal preference. You can read more about bladder reconstruction below and discuss your options with your care team.
Urostomy or urinary diversion
Urostomy is the most common procedure and involves creating an alternative opening of the urinary system. This can be done in two ways:
- Ileal conduit – which allows urine to drain into a bag attached to the outside of the abdomen. The doctor uses a piece of your small intestine (ileum) to create a passageway (conduit) that connects between the ureters and an opening on the outside of the body (stoma). A watertight bag is placed over the stoma to collect the urine. The bag fills continuously and needs to be emptied throughout the day through a tap on the bag.
- Continent urinary diversion – which allows urine to be stored inside the abdomen for a period of time before being removed through a stoma (opening). The doctor uses a piece of bowel to form a pouch with a valve. The pouch is connected to the ureters and the pouch valve is joined to the surface of the abdomen where the stoma is created. A drainage tube (catheter) should be inserted through the stoma several times a day, to collect and drain the urine.
This procedure involves the creation of a new bladder using a segment of the bowel. The surgeon uses about 45-75 cm of your small bowel to make a new bladder which is stitched to the top of your urethra. The ureters are stitched to the top area of the neobladder so that urine drains directly into it from the kidneys.
Having a neobladder usually means you can urinate normally (without a stoma). However, you will need to go to the toilet regularly, as you will have lost the nerves that tell you when your bladder is full. Sometimes this nerve loss can lead to slight incontinence (inability to control the flow of urine). A continence nurse will teach you how to urinate with the neobladder and also how to drain it with a catheter in case you are not able to empty it with your abdominal muscles.
This procedure is less common and is not suitable for most types of bladder cancer. A partial cystectomy involves the removal of the bladder tumour and a margin of healthy tissue around it. After a partial cystectomy, your bladder will be smaller and will hold less urine, so you may need to pass urine more often.
Radiotherapy uses high energy X-rays to kill cancer cells or injure them so they cannot multiply. Radiotherapy may be used to treat invasive bladder cancer so the bladder does not have to be removed, but it is unlikely to cure the cancer alone. Chemotherapy is often given with radiotherapy so the cells will be made more sensitive to the radiation.
The course of treatment is usually five sessions from Monday to Friday, for several weeks. The length of treatment will depend on the type and size of the cancer.
Chemotherapy involves the use of cytotoxic drugs to treat cancer by killing cancer cells or slowing their growth. Chemotherapy for invasive bladder cancer is given intravenously (into a vein) over the course of a few days. The drugs are given every few weeks for several months. It is often called systematic chemotherapy to distinguish it from intravesical chemotherapy, which is used to treat non-invasive bladder cancer.
You may have systemic chemotherapy:
- before surgery to shrink the cancer and make it easier to operate
- after surgery if there is a high risk of the cancer coming back with radiotherapy if the cancer has spread to other parts of the body.
For more information about treatment, including side effects, you may like to visit the Cancer Council NSW website:
Palliative treatment helps improve quality of life by alleviating the symptoms of cancer without trying to cure the disease. It is particularly important for people with advanced cancer.
Sometimes treatment is concerned with pain relief and stopping the spread of cancer. In other cases, it manages emotional symptoms of cancer.
Palliative treatment may involve radiotherapy, chemotherapy and other medication.