Bladder cancer

Bladder cancer is when cells in the lining of your bladder start to grow abnormally and multiply in an uncontrolled way to form a tumour.

Around 70% of cases of bladder cancer are non-muscle-invasive (superficial), which means the cancer cells have stayed in the lining of your bladder. At this stage, half of people diagnosed with non-muscle-invasive bladder cancer have a good chance of successfully managing it with regular surveillance and treatment for 10 years or more.

Other bladder cancer tumours grow into the muscle wall of the bladder. This is called invasive bladder cancer.

Sometimes bladder cancer spreads to other parts of the body. This is called advanced or metastatic bladder cancer.

There's no national screening programme in the UK for bladder cancer but earlier detection can improve your prognosis.

The main bladder cancer symptom is blood in your urine, which is usually bright red but not painful — this is called haematuria. You may not be able to see small amounts of blood in your urine — this is called microscopic haematuria and is detected with a urine test. If you can see the blood in your urine, it is called gross haematuria.

It’s important to see your GP if you notice blood in your urine. Even if it isn’t there all the time, it’s important to find out the cause. Blood in your urine may be caused by: 

• A kidney infection
• A urinary tract infection eg cystitis
• An enlarged prostate gland
• Kidney stones
• Urethritis

Other bladder cancer symptoms include:

• Needing to urinate frequently
• Needing to urinate urgently
• Pain when urinating

However, these are often symptoms of other conditions, such as a bladder infection or enlarged prostate.

Different types of cells in your bladder can become cancerous. The type of bladder cancer you have depends on which cell type becomes cancerous. This will also determine the most appropriate treatment for you. There are three main types of bladder cancer:

Urothelial carcinoma 

Formerly called transitional cell carcinoma, this cancer occurs in the cells lining the inside of your bladder called urothelial cells. Urothelial cells expand when your bladder is full and shrink when your bladder is empty. These cells also line the inside of your ureters (tubes that connect your kidneys to your bladder) and urethra — bladder cancer can therefore start in these locations too. Urothelial carcinoma is the most common type of bladder cancer in the UK.

Squamous cell carcinoma

This cancer is more common if you have chronic (long-term) irritation of your bladder eg due to infections or long-term use of a urinary catheter. It is rare in the UK. It is more common in countries where schistosomiasis is common — this is a parasitic infection that can affect multiple organs including the bladder. 

Adenocarcinoma 

This is a very rare type of bladder cancer in the UK. It starts in cells that form the glands that secrete mucus in your bladder. 

Cancer can be diagnosed according to different stages, which depend on how far the cancer has spread. Lower stages have a better chance of successful treatment as the cancer is smaller. 

Bladder cancers can be staged according to TNM system. T refers to how far into the bladder the tumour has grown. N refers to whether the cancer has spread into nearby lymph nodes. M refers to whether the cancer has spread into another part of the body (metastasis).

The T stages are: 

• TIS or CIS (carcinoma in situ) — a very early, faster-growing (high-grade) cancer, which is limited to the innermost layer of the bladder lining
• Ta — cancer is limited to the innermost layer of the bladder lining
• T1 — cancer has grown beyond the bladder lining and into the connective tissue
• T2 — cancer has grown beyond the bladder lining and connective tissue, and into the bladder muscle
• T3 — cancer has grown beyond the bladder lining, connective tissue and muscle layers, and into the surrounding fat layer
• T4 — cancer has spread beyond the bladder and into surrounding organs

Bladder cancer up to the T1 stage is usually called early-stage bladder cancer or non-muscle-invasive bladder cancer. After the T2 stage, bladder cancer is usually called muscle-invasive bladder cancer. After the T3 stage, bladder cancer is advanced. 

The N stages are:

• N0 — no cancer cells in any of your lymph nodes
• N1 — cancer cells in just one of your lymph nodes in your pelvis
• N2 — cancer cells in two or more lymph nodes in your pelvis
• N3 — cancer cells in one or more of your lymph nodes deep in your pelvis (ie in your common iliac nodes) 

The M stages are: 

• M0 — cancer has not spread to another part of your body
• M1 — cancer has spread to another part of the body eg your bones, lungs or liver

Bladder cancer can occur at any age but your risk increases as you get older; most people with bladder cancer are aged 55 or over. You are also at greater risk if you are male. Other risk factors include: 

• Chronic or recurring urinary infections or inflammation (cystitis) — this may occur with long-term use of a urinary catheter or due to the parasitic infection schistosomiasis; chronic inflammation increases your risk of squamous cell bladder cancer 
• Exposure to harmful chemicals — when you are exposed to harmful chemicals your body processes them and they can build up in your urine, which can damage the lining of your bladder; chemicals linked to bladder cancer include arsenic and chemicals used in making dyes, rubber, leather, textiles and paint
• Personal or family history of cancer — if you have previously had bladder cancer, you are more likely to get it again; your risk is also higher if a genetically related family member has had bladder cancer, although it doesn't usually run in families; a family history of Lynch syndrome (hereditary nonpolyposis colorectal cancer (HNPCC)) can increase your risk of cancer in several different organs including the bladder, colon, womb and ovaries
• Previous cancer treatment — treatment with the anti-cancer drug cyclophosphamide and radiation treatment targeting your pelvis to treat a previous cancer both increase your risk of bladder cancer
• Smoking — harmful chemicals in cigarettes, cigars or pipe tobacco are processed by your body and build up in your urine, which can damage the lining of your bladder

If you have any symptoms of bladder cancer you should see your GP. They will:

• Ask about your symptoms and risk factors
• Perform an internal examination to make sure the problem isn’t your womb or prostate gland, which can cause similar symptoms
• Take a urine sample to: 
• Perform a urine cytology test — this checks for tumour cells in your urine
• See if you have an infection 

You may be referred to a urologist, a consultant specialising in the urinary system. 

Bladder cancer is usually diagnosed with a cystoscopy — a procedure to look inside your bladder and check for growths using a thin, telescope-like tube with a camera at the end called a cystoscope. This can be performed under a local anaesthetic (flexible cystoscopy) or a general anaesthetic. If your doctor detects abnormal tissue during your cystoscopy, they may carry out a biopsy at the same time. 

During your cystoscopy, your bladder may also be rinsed out and the liquid collected, either via the cystoscope or a small tube passed into your urethra — the liquid can then be sent for a cytology test. 

Other diagnostic tests are:

CT scans

A CT scan involves using X-rays to take pictures of the inside of your body from different angles. A computer then combines these into a detailed 3D image. This allows your doctor to detect abnormalities or growths and take measurements of any tumours or enlarged lymph nodes, which may suggest the cancer has spread. 

Intravenous urogram

This involves using a contrast agent to highlight your urinary tract on an X-ray.

Ultrasound scans

An ultrasound scan uses sound waves to create detailed images of the inside of your body to check if your kidneys or ureters are blocked. You do not need to take any contrast agent.

MRI scans

An MRI scan uses magnetic fields to create detailed images of the inside of your body. First, a special dye is injected into your vein or taken orally as a tablet or liquid — this improves the contrast of the images taken during your MRI scan. This type of scan allows your doctor to detect abnormalities or growths and take measurements of any tumours or enlarged lymph nodes, which may suggest the cancer has spread.

Positron emission tomography (PET) scan combined with a CT scan (PET-CT scan)

This is often just called a PET scan. A small amount of a radioactive substance is injected into your vein and is taken up by cells that use a lot of energy, such as cancer cells. A scanner detects the radioactive substance and creates images of the inside of your body.

If you’re diagnosed with bladder cancer, your doctor will tell you the type, stage and the grade of your cancer. They'll also tell you if there's any metastasis (spreading) to other parts of your body. This is important to help them decide the most effective treatment options for you.

Bladder cancer is usually diagnosed in people over 55. It's also more common in men than women.

There are other risk factors that increase your risk of developing bladder cancer. These are:

• A chronic bladder infection or a neurological condition that affects your bladder control (neurogenic bladder)
• A close relative with bladder or upper urinary tract cancer
• Being a smoker
• Exposure to chemicals used in the textile, rubber, leather, dye, paint and print industries — usually through your workplace
• Previous radiotherapy to your pelvis

Treatment depends on the type of bladder cancer, the stage and the grade. 

If your bladder cancer is in the non-muscle-invasive stage it can be removed with a surgical procedure called Transurethral Resection of Bladder Tumour (TURBT). This may be followed by chemotherapy directly to your bladder.

Higher risk tumours are treated with a chemotherapy drug injected into your bladder.

Muscle-invasive cancers may need complete removal of your bladder and nearby lymph nodes (radical cystectomy) followed by radiotherapy.

Bladder cancer sometimes recurs in the months and years after treatment so you’ll need regular follow-up appointments and cystoscopies.

Physical and emotional side effects of treatment

Cancer and cancer treatment cause physical and emotional side effects and can also affect your social life and financial circumstances. 

The management of all of these effects is called supportive care or palliative care. It is vital to your overall care and is delivered alongside your medical treatments to help eliminate, slow or stop the cancer. 

Palliative treatments vary considerably and can include: 

• Emotional and spiritual support
• Medication
• Nutritional changes
• Relaxation techniques

Palliative treatments can also include treatments similar to those used to eliminate the cancer eg chemotherapy, radiation therapy and surgery.

There is no guaranteed way to prevent bladder cancer. However, you can reduce your risk by:

• Being careful around chemicals — if you work with chemicals, follow safety instructions to reduce your risk of exposure; chemical exposure is estimated to be responsible for up to a quarter of cases of bladder cancer; chemicals that increase your risk of bladder cancer include: 
• 2-Naphthylamine
• 4-Aminobiphenyl
• Aniline dyes
• Benzidine
• O-toluidine
• Xenylamine
• Eating a healthy, balanced diet — a diet rich in colourful fruits and vegetables may reduce your risk of bladder cancer as they contain antioxidants
• Not smoking — don't start smoking and if you already do smoke, quit; see your GP for help to quit smoking, they can recommend medications, support groups and other methods