Bladder Cancer: Types, Stages and Treatment

What bladder cancer is

The bladder is lined by a layer of cells called the urothelium, which also lines the kidneys' drainage system, the ureters and the urethra. Below it lie connective tissue, a thick muscle layer and fat. Bladder cancer starts in the lining. How far it has grown into those deeper layers determines the treatment and outlook.

Because the whole urinary lining is exposed to the same chemicals in urine, people with bladder cancer can develop new tumors elsewhere in the bladder or upper urinary tract over time. This is called a field effect.

Symptoms

Most people first notice painless blood in the urine, often coming and going. Others have urgency, frequency or burning without a urinary tract infection. Late symptoms include pelvic pain, back pain, leg swelling and weight loss. See bladder cancer symptoms for early warning signs and how they differ from infection or stones.

Causes and risk factors

• Smoking: chemicals from tobacco are filtered into urine and damage the bladder lining. Smokers have about 3 times the risk of non-smokers. Risk falls after quitting, but slowly.
• Occupational exposure: aromatic amines and other chemicals in dye, rubber, leather, textile, paint and printing industries, and among truck drivers and hairdressers in older studies.
• Age and sex: average age at diagnosis is about 73; men are more often affected.
• Medical exposures: pelvic radiation, cyclophosphamide, pioglitazone (small possible link), and aristolochic acid in some herbal remedies.
• Chronic irritation: long-term catheters, repeated bladder stones, and schistosomiasis, which mainly causes squamous cell carcinoma.
• Arsenic in drinking water.
• Genetics: Lynch syndrome raises the risk of upper urinary tract cancer.

Types of bladder cancer

Tumors are also graded as low grade (slow-growing, rarely invade, often recur) or high grade (more likely to invade and spread).

Stages

Doctors use the TNM system. The key divide is whether the cancer has reached the muscle wall.

Non-muscle-invasive bladder cancer (NMIBC) covers Ta, Tis and T1. Muscle-invasive bladder cancer (MIBC) is T2 and above.

Diagnosis

1. Cystoscopy: a camera examines the bladder lining.
2. TURBT (transurethral resection of bladder tumor): under anesthesia, the tumor is removed through the urethra. This both treats and stages it, because the pathologist checks for muscle in the sample.
3. Urine cytology for cancer cells.
4. CT urogram to check the kidneys and ureters, where kidney cancer of the same cell type can occur.
5. CT or MRI of the chest, abdomen and pelvis, and sometimes a PET scan, for invasive cancer.

Treatment

Non-muscle-invasive bladder cancer

• TURBT removes all visible tumors.
• A single dose of chemotherapy placed in the bladder within 24 hours after TURBT lowers the recurrence risk for low-grade tumors.
• BCG (bacillus Calmette-Guerin) immunotherapy: a weakened bacterium placed in the bladder weekly for 6 weeks, then as maintenance for 1 to 3 years. It is the standard for high-grade tumors and carcinoma in situ, and reduces both recurrence and progression. Side effects include burning, frequency and flu-like symptoms for a day or two.
• Repeat TURBT within 2 to 6 weeks for high-grade T1 tumors.
• Radical cystectomy may be offered for very high-risk tumors or those that do not respond to BCG. Newer bladder-sparing drugs are options for some BCG-unresponsive cancers.

Muscle-invasive bladder cancer

• Chemotherapy before surgery (cisplatin-based), followed by radical cystectomy: removal of the bladder and nearby lymph nodes, plus the prostate in men (which also removes any hidden prostate cancer) and often the uterus and part of the vagina in women.
• Urinary diversion after cystectomy: an ileal conduit (urine drains into a bag on the abdomen) or a neobladder made from bowel that you empty through the urethra.
• Trimodal bladder-sparing therapy: maximal TURBT followed by radiotherapy with chemotherapy, for selected patients. Outcomes can be similar to surgery in well-chosen cases.
• Immunotherapy after surgery is used for some higher-risk cancers.

Advanced or metastatic bladder cancer

Treatment aims to control the cancer and symptoms. Options include combinations of chemotherapy and immunotherapy (checkpoint inhibitors), antibody-drug conjugates such as enfortumab vedotin, targeted drugs for FGFR gene changes, and palliative radiotherapy. Newer combinations have improved survival in recent years.

Follow-up and recurrence

Up to half or more of non-muscle-invasive cancers come back within 5 years, so follow-up is intense: cystoscopy every 3 months at first, spacing out over several years, plus periodic upper tract imaging for high-risk disease. Most recurrences are caught early and treated again by TURBT.

Outlook

According to US National Cancer Institute data, about 4 in 5 people diagnosed with bladder cancer are alive 5 years later. Survival depends strongly on stage: very high for cancer confined to the lining, lower once it invades the muscle, and much lower for cancer that has spread to distant organs.

Prevention

• Stop smoking. This is the most effective step, and risk drops over the following years.
• Follow workplace safety rules if you handle industrial chemicals.
• Drink enough fluids; some evidence suggests this may lower risk.
• There is no routine screening program for people without symptoms.

Frequently asked questions

Is bladder cancer curable?

Often, yes. Most bladder cancers are found before they invade the muscle and can be removed through the urethra, though they commonly recur and need monitoring. Muscle-invasive cancer can also be cured with surgery or chemoradiation in many people. Cancer that has spread is usually not curable but can be controlled.

What are the stages of bladder cancer?

Stages run from Ta and Tis (confined to the lining) and T1 (just under the lining) to T2 (into muscle), T3 (through the muscle), T4 (into nearby organs), and then lymph node and distant spread. The key distinction is non-muscle-invasive versus muscle-invasive disease.

What is BCG treatment for bladder cancer?

BCG is a weakened form of a bacterium related to tuberculosis. Placed in the bladder through a catheter, it triggers the immune system to attack cancer cells. It is the standard treatment after surgery for high-grade early bladder cancer and carcinoma in situ.

Can you live without a bladder?

Yes. After a radical cystectomy, urine is redirected through an ileal conduit to a bag on the abdomen, into a neobladder made from bowel, or into an internal pouch emptied with a catheter. Most people return to work, travel and exercise.

How fast does bladder cancer grow?

Low-grade bladder cancers grow slowly and rarely spread, but often recur. High-grade cancers can grow and invade the muscle over months. That is why visible blood in the urine should be checked promptly and why follow-up cystoscopies matter.