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What is bladder cancer?

Cancer can start any place in the body. Cancer that starts in the bladder is called bladder cancer. It starts when cells in the bladder grow out of control and crowd out normal cells. This makes it hard for the body to work the way it should.

Bladder cancer cells can sometimes spread to other parts of the body, such as the bones, and grow there. This spread is called metastasis. Even if bladder cancer spreads to the bones (or any other place), the cancer cells there are still bladder cancer cells.

The bladder

The bladder is a hollow organ that stores urine before it leaves your body. It sits in the lowest part of your belly, called your pelvis. Urine is made in your kidneys. Tubes called ureters connect your kidneys to the bladder. Urine flows through the ureters and into your bladder, where it's stored. When you urinate (pee), the bladder squeezes the urine out through a tube called the urethra.

Bladder cancer usually starts in the inner layer of the bladder wall. As the cancer grows through the layers of the bladder wall, it becomes harder to treat.

The "transitional epithelium" in the picture below is the lining layer where most bladder cancers start. Over time they can spread deeper into the other layers.

Ask your doctor to use this picture to show you where the cancer is.

Questions to ask the doctor

• Why do you think I have bladder cancer?
• Is there a chance I don’t have cancer?
• Would you please write down the kind of cancer you think I might have?
• What will happen next?

How does the doctor know I have bladder cancer?

Signs and symptoms of bladder cancer are problems peeing, pain when peeing, needing to go more often than normal, and seeing blood in your urine.

If signs suggest you might have bladder cancer, exams and tests will be done. Here are some of the tests you may need:

Physical exam: The doctor will check you for signs of bladder cancer and other health problems. This might include a rectal exam, during which a gloved finger is put into your rectum. If you are a woman, a pelvic exam might also be done. During these exams, the doctor can sometimes feel a bladder tumor.

Urine tests: For these tests, you'll be asked to pee in a cup. Your urine is then tested for cancer cells, blood, or certain proteins (called biomarkers or tumor markers).

Cystoscopy: For this exam, a doctor called a urologist looks at the inside of your bladder using a tool called a cystoscope. This is a thin tube with a tiny light and camera on its end. It's put through the opening of your urethra and moved up into your bladder. This exam can also be used to remove (biopsy) small pieces of the bladder wall, which can then be tested for cancer. Saltwater washings of the inside of your bladder may also be collected to look for cancer cells.

Blue light cystoscopy: Sometimes, special drugs are put into the bladder during the exam. Cancer cells soak up these drugs and then glow when the doctor shines a blue light through the scope. This can help the doctor see cancer cells that might have been missed with the normal light.

TURBT: In this procedure, a rigid cystoscope called a resectoscope is put into the bladder. This lets the doctor remove tumors as well as some of the muscle layer of the bladder wall, which can then be checked in the lab for cancer cells. A TURBT can also be a form of treatment for early bladder cancers.

Lab tests of biopsy samples: Any samples removed during either a cystoscopy or a TURBT are tested in the lab for cancer cells. This is needed to know for sure if you have bladder cancer. Other tests may be done on the cells to learn more about the cancer.

CT scan: This is sometimes called a CAT scan. It uses x-rays to make detailed pictures of the inside of your body. It can show if the cancer has spread outside the bladder.

MRI: MRIs use radio waves and strong magnets instead of x-rays to take detailed pictures. MRIs can be very helpful in finding cancer that has spread outside the bladder.

Ultrasound: This test uses sound waves to make pictures of the organs inside your body, like your bladder and kidneys. It can help show the size of a bladder cancer and if it has spread.

X-ray tests: These tests aren’t usually done, because other tests such as CT or MRI scans are often all that’s needed. For one type of x-ray test (called an IVP), a dye is put into a vein for a special x-ray of the kidneys, ureters, and bladder. The dye highlights these so the doctor can better see them and any tumors.

PET scan: This test may be done to see if the cancer has spread. To do it, a small amount of a low-level radioactive substance is put into your blood. It attaches to cancer cells anywhere in the body. A special camera can then show any areas of radioactivity. Sometimes this test is done at the same time as a CT scan (PET-CT).

Bone scan: A bone scan can help show if bladder cancer has spread to the bones. This test is not done unless you have bone pain.

Questions to ask the doctor

• What tests will I need?
• Who will do these tests?
• Where will they be done?
• How and when will I get the results?
• Who can explain the results to me?
• What do I need to do next?

How serious is my cancer?

If bladder cancer is found, certain features of the cancer cells help the doctor know how best to treat it.

Invasiveness

Tests can show how deeply the cancer has grown into the bladder wall. This can help tell which treatment might be best. Bladder cancers are often divided into 2 main groups:

• Non-muscle invasive bladder cancer (NMIBC) hasn’t yet grown deep enough to reach the main muscle layer of the bladder wall.
• Muscle invasive bladder cancer (MIBC) has grown into the muscle layer of the bladder wall, and possibly deeper. These cancers are more likely to spread, and they tend to be harder to treat.

Grade

The grade refers to how the cancer looks under the microscope.

• Low-grade bladder cancers look a lot like normal bladder cells. They tend to grow and spread slowly.
• High-grade bladder cancers look less like normal bladder cells. These cancers are more likely to grow and spread. They can be harder to treat.

Gene and protein changes

Lab tests may be done to check the cancer cells for certain gene or protein changes (sometimes called biomarkers). This might affect your treatment options.

Stage

Your doctor will also want to find out the stage of your cancer to help decide what type of treatment is best for you. The stage describes the growth or spread of the cancer in the bladder, as well as if it has spread to other parts of your body.

Your cancer can be stage 0, 1, 2, 3, or 4. The lower the number, the less the cancer has spread. A higher number, like stage 4, means a more serious cancer that has spread outside the bladder. Ask your doctor about the cancer stage and what it means for you.

Risk groups

If you have NMIBC, the cancer might also be put into a risk group (low, intermediate, or high), based on certain factors. This can give doctors an idea of how likely it is that the cancer will come back or keep growing, which might affect your treatment options.

Questions to ask the doctor

• Has the cancer invaded the muscle layer of the bladder?
• Do you know the stage and grade of the cancer?
• If not, how and when will you find out the stage and grade?
• Would you explain what these mean in my case?
• What will happen next?

What kind of treatment will I need?

There are many ways to treat bladder cancer. You might want to get a second opinion about the best treatment plan for you.

Bladder cancer is most often treated with:

• Surgery
• Intravesical treatment
• Radiation
• Chemotherapy (chemo)
• Immune therapy
• Targeted drugs

Sometimes more than one type is used. The treatment plan that’s best for you depends on:

• The stage and grade of the cancer
• How far the cancer has spread into the bladder wall
• The chance that a type of treatment will cure the cancer or help in some way
• Any other health problems you have
• Your feelings about the treatment and the side effects that come with it

Surgery for bladder cancer

Surgery is done for most bladder cancers. The type you have depends on the stage of the cancer and other factors, such as your health and preferences.

Removing the tumor from the inside bladder (a transurethral resection of bladder tumor, or TURBT) is the most common surgery for early bladder cancer. This can be done during a cystoscopy.

When the cancer is more invasive, the cancer is removed along with part of the bladder (partial cystectomy) or the entire bladder (radical cystectomy).

If only part of the bladder is removed, you'll still be able to hold and release urine as normal, though in smaller amounts. If the entire bladder is removed, you'll need another way to store and pass urine. Your doctor can explain the options for this.

Side effects of surgery

Any type of surgery can have some risks and side effects. For instance, removing the bladder not only changes how your body passes urine, but it can also cause sexual side effects. If you have these or any other problems, let your doctors know. There are ways to help deal with many side effects.

Intravesical treatment

For this treatment, a drug is put inside the bladder. This might be a chemo drug or a drug such as BCG that boosts the immune system. This is often done after surgery in people who still have their bladder. It can help lower the chance that the cancer will come back in the bladder.

The drug affects the cells lining the inside of the bladder, but it has little to no effect on cells in other places. This can help limit side effects. But this also means it can’t treat invasive bladder cancers or those that have spread outside the bladder.

Side effects of intravesical treatment

Some people have a burning feeling in their bladder after treatment. Other side effects depend on which drug is used. Some side effects may feel like having the flu, such as fever, chills, and feeling tired.

Chemo

Chemo is the use of drugs to kill cancer cells. The drugs may be given into a vein or taken as pills. They go into the blood and spread through the body.

For early-stage bladder cancers, chemo may be used:

• Before surgery to shrink a tumor
• After surgery to kill any cancer cells that remain
• With radiation to help it work better
• As a treatment for advanced bladder cancers, such as those that have spread to other parts of the body

Chemo is given in cycles or rounds. Each round of treatment is followed by a break. Most of the time, 2 or more chemo drugs are given. Treatment often lasts for many months.

Side effects of chemo

Chemo can make you feel very tired, sick to your stomach, and cause your hair to fall out. But these problems go away after treatment ends.

There are ways to treat most chemo side effects. If you have side effects, talk to your cancer care team so they can help.

Radiation treatment

In radiation therapy, a machine sends x-rays to a specific part of the body to kill cancer cells.

Radiation treatment for bladder cancer can be used:

• To treat early-stage cancer after surgery
• As the main treatment for early-stage cancer if you can't have (or don’t want) surgery
• As part of the treatment for advanced bladder cancer

Radiation is often given along with chemo. Certain chemo drugs can help the radiation work better.

Side effects of radiation treatments

The most common side effects of radiation to the bladder are:

• Skin changes where the radiation goes into your body, such as redness or blistering
• Nausea and vomiting
• Burning or pain when you urinate, feeling the need to go often, or blood in urine
• Loose stools
• Feeling tired
• Easy bruising or bleeding
• Increased risk of infection

Most side effects get better after treatment ends. Some might last longer. Talk to your doctor about what you can expect.

Immunotherapy

Immunotherapy is treatment that boosts your immune system to attack the cancer cells. Different types of immunotherapy can be used to treat bladder cancer. These drugs can either be put right into the bladder (as a liquid) to treat some early-stage bladder cancers, or they can be given into a vein to help treat more advanced bladder cancers.

Side effects of immunotherapy

Immunotherapy can cause different side effects depending on which drug is used. Most side effects tend to be mild, such as feeling tired or having an upset stomach, but in some people the side effects can be serious. Most side effects go away after treatment ends.

If you have side effects, talk to your cancer care team so they can help.

Targeted drugs

Targeted drugs may be used for some advanced bladder cancers. These drugs affect cancer cells more than normal cells in the body. They may work even if other treatments don’t. These drugs ted to have different side effects than chemo drugs.

Clinical trials

Clinical trials are research studies that test new drugs or other treatments in people. They compare standard treatments with others that may be better.

Clinical trials are one way to get the newest cancer treatment. They are the best way for doctors to find better ways to treat bladder cancer. If your doctor can find one that might be right for you, it’s up to you whether to take part. And if you do sign up for a clinical trial, you can always stop at any time.

If you'd like to learn more about clinical trials that might be right for you, start by asking your doctor if your clinic or hospital conducts clinical trials. See Clinical Trials to learn more.

What about other treatments that I hear about?

When you have bladder cancer, you might hear about other ways to treat cancer or treat your symptoms that are not standard medical treatments. These treatments can be vitamins, herbs, special diets, and other things. You may be curious about these treatments.

Some of these are known to help, but many have not been tested. Some have been shown not to help. A few have even been found to be harmful. Talk to your doctor about anything you're thinking about using, whether it’s a vitamin, a diet, or anything else.

Questions to ask the doctor

• What are my treatment options?
• What treatment do you think is best for me? Why?
• What’s the goal of this treatment? Do you think it could cure the cancer?
• Will treatment include surgery? If so, who will do the surgery?
• What will the surgery be like?
• Does my bladder need to be removed? If so, how will I pee after surgery?
• Will I have other types of treatment?
• What’s the goal of these treatments?
• What should I do to be ready for treatment?
• Is there anything I can do to help the treatment work better?
• What side effects could I have from these treatments?
• Is there a clinical trial that might be right for me?
• What about treatments like special vitamins or diets that friends tell me about? How will I know if they are safe?
• What’s the next step?

What will happen after treatment?

You'll be glad when treatment is over. But it can be hard not to worry about the cancer coming back. Even when cancer never comes back, people still worry about this. For years after treatment ends, you will see your cancer doctor. Be sure to go to all of your follow-up visits. People who have had bladder cancer are at high risk of having a second bladder cancer.

If you have no signs of cancer, most experts advise seeing your doctor every 3 to 6 months. These visits might include urine tests, blood work, and other tests. If you still have your bladder, you will need regular exams of your bladder, too. The time between doctor visits may be longer after a few years if no new cancers are seen.

Having cancer and dealing with treatment can be hard, but it can also be a time to look at your life in new ways. You might be thinking about how to improve your health. Call us or talk to your doctor to find out what you can do to feel better.

You can’t change the fact that you have cancer. What you can change is how you live the rest of your life, making healthy choices and feeling as well as you can.