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Bladder cancer

Overview

Bladder cancer is one of the most common cancers, affecting approximately 68,000 adults in the United States each year. Bladder cancer occurs in men more frequently than it does in women and usually affects older adults, though it can happen at any age.

Bladder cancer most often begins in the cells (urothelial cells) that line the inside of your bladder — the hollow, muscular organ in your lower abdomen that stores urine. Although it's most common in the bladder, this same type of cancer can occur in other parts of the urinary tract drainage system.

About seven out of every 10 bladder cancers diagnosed start out at an early stage — when bladder cancer is highly treatable. However, even early-stage bladder cancer may recur in the bladder. For this reason, people with bladder cancer typically need follow-up tests for years after treatment to look for bladder cancer that recurs or advances to a higher stage.

Female urinary system

Your urinary system — which includes your kidneys, ureters, bladder and urethra — removes waste from your body through urine. Your kidneys, located in the rear portion of your upper abdomen, produce urine by filtering waste and fluid from your blood.

Female urinary system

Your urinary system — which includes your kidneys, ureters, bladder and urethra — removes waste from your body through urine. Your kidneys, located in the rear portion of your upper abdomen, produce urine by filtering waste and fluid from your blood.

Male urinary system

Your urinary system — which includes your kidneys, ureters, bladder and urethra — removes waste from your body through urine. Your kidneys, located in the rear portion of your upper abdomen, produce urine by filtering waste and fluid from your blood.

Symptoms

Bladder cancer signs and symptoms may include:

  • Blood in urine (hematuria)
  • Painful urination
  • Pelvic pain

If you have hematuria, your urine may appear bright red or cola colored. Sometimes, urine may not look any different, but blood in urine may be detected during a microscopic exam of the urine.

People with bladder cancer might also experience:

  • Back pain
  • Frequent urination

But, these symptoms often occur because of something other than bladder cancer.

When to see a doctor

If you have blood in your urine (hematuria), make an appointment with your doctor to get it checked out. Also make an appointment with your doctor if you have other signs or symptoms that worry you.

Causes

Bladder cancer develops when cells in the bladder begin to grow abnormally. Rather than grow and divide in an orderly way, these cells develop mutations that cause them to grow out of control and not die. These abnormal cells form a tumor.

Causes of bladder cancer include:

  • Smoking and other tobacco use
  • Exposure to chemicals, especially working in a job that requires exposure to chemicals
  • Past radiation exposure
  • Chronic irritation of the lining of the bladder
  • Parasitic infections, especially in people who are from or have traveled to certain areas outside the United States

It's not always clear what causes bladder cancer, and some people with bladder cancer have no obvious risk factors.

Types of bladder cancer

Different types of cells in your bladder can become cancerous. The type of bladder cell where cancer begins determines the type of bladder cancer. The type of bladder cancer determines which treatments may work best for you.

Types of bladder cancer include:

  • Urothelial carcinoma. Urothelial carcinoma, previously called transitional cell carcinoma, occurs in the cells that line the inside of the bladder. Urothelial cells expand when your bladder is full and contract when your bladder is empty. These same cells line the inside of the ureters and the urethra, and tumors can form in those places as well. Urothelial carcinoma is the most common type of bladder cancer in the United States.
  • Squamous cell carcinoma. Squamous cell carcinoma is associated with chronic irritation of the bladder, for instance from an infection or from long-term use of a urinary catheter. Squamous cell bladder cancer is rare in the United States. It's more common in parts of the world where a certain parasitic infection (schistosomiasis) is a common cause of bladder infections.
  • Adenocarcinoma. Adenocarcinoma begins in cells that make up mucus-secreting glands in the bladder. Adenocarcinoma of the bladder is rare in the United States.

Some bladder cancers include more than one type of cell.

Bladder cancer

Bladder cancer develops when cells in the bladder begin to grow abnormally, forming a tumor in the bladder.

Risk factors

Factors that may increase bladder cancer risk include:

  • Smoking. Smoking cigarettes, cigars or pipes may increase the risk of bladder cancer by causing harmful chemicals to accumulate in the urine. When you smoke, your body processes the chemicals in the smoke and excretes some of them in your urine. These harmful chemicals may damage the lining of your bladder, which can increase your risk of cancer.
  • Increasing age. Bladder cancer risk increases as you age. Bladder cancer can occur at any age, but it's rarely found in people younger than 40.
  • Being white. White people have a greater risk of bladder cancer than do people of other races.
  • Being a man. Men are more likely to develop bladder cancer than women are.
  • Exposure to certain chemicals. Your kidneys play a key role in filtering harmful chemicals from your bloodstream and moving them into your bladder. Because of this, it's thought that being around certain chemicals may increase the risk of bladder cancer. Chemicals linked to bladder cancer risk include arsenic and chemicals used in the manufacture of dyes, rubber, leather, textiles and paint products.
  • Previous cancer treatment. Treatment with the anti-cancer drug cyclophosphamide increases the risk of bladder cancer. People who received radiation treatments aimed at the pelvis for a previous cancer have an elevated risk of developing bladder cancer.
  • Chronic bladder inflammation. Chronic or repeated urinary infections or inflammations (cystitis), such as might happen with long-term use of a urinary catheter, may increase the risk of a squamous cell bladder cancer. In some areas of the world, squamous cell carcinoma is linked to chronic bladder inflammation caused by the parasitic infection known as schistosomiasis.
  • Personal or family history of cancer. If you've had bladder cancer, you're more likely to get it again. If one of your first-degree relatives — a parent, sibling or child — has a history of bladder cancer, you may have an increased risk of the disease, although it's rare for bladder cancer to run in families. A family history of hereditary nonpolyposis colorectal cancer, also called Lynch syndrome, can increase the risk of cancer in the urinary system, as well as in the colon, uterus, ovaries and other organs.

Prevention

Although there's no guaranteed way to prevent bladder cancer, you can take steps to help reduce your risk. For instance:

  • Don't smoke. Not smoking means that cancer-causing chemicals in smoke can't collect in your bladder. If you don't smoke, don't start. If you smoke, talk to your doctor about a plan to help you stop. Support groups, medications and other methods may help you quit.
  • Take caution around chemicals. If you work with chemicals, follow all safety instructions to avoid exposure.
  • Choose a variety of fruits and vegetables. Choose a diet rich in a variety of colorful fruits and vegetables. The antioxidants in fruits and vegetables may help reduce your risk of cancer.

Diagnosing bladder cancer

Tests and procedures used to diagnose bladder cancer may include:

  • Cystoscopy. To perform cystoscopy, your doctor inserts a small, narrow tube (cystoscope) through the urethra. The cystoscope has a lens that allows your doctor to see the inside of your urethra and bladder, to examine these structures for signs of disease.
  • Biopsy. During cystoscopy, your doctor may pass a special tool through the scope and into your bladder to collect a cell sample (biopsy) for testing. This procedure is sometimes called transurethral resection of bladder tumor (TURBT). TURBT can also be used to treat bladder cancer.
  • Urine cytology. A sample of your urine is analyzed under a microscope to check for cancer cells in a procedure called urine cytology.
  • Imaging tests. Imaging tests, such as computerized tomography (CT) urogram or retrograde pyelogram, allow your doctor to examine the structures of your urinary tract.

    During a CT urogram, a contrast dye injected into a vein in your hand eventually flows into your kidneys, ureters and bladder. X-ray images taken during the test provide a detailed view of your urinary tract and help your doctor identify any areas that might be cancer.

    Retrograde pyelogram is an X-ray exam used to get a detailed look at the upper urinary tract. During this test, your doctor threads a thin tube (catheter) through your urethra and into your bladder to inject contrast dye into your ureters. The dye then flows into your kidneys while X-ray images are captured.

Staging bladder cancer

After confirming that you have bladder cancer, your doctor may order additional tests to determine how extensive your cancer is. Your doctor needs to know the stage and grade of your cancer to recommend the best treatment options for you.

Tests may include:

  • CT scan
  • Magnetic resonance imaging (MRI)
  • Bone scan
  • Chest X-ray

Bladder cancer stages

The stages of bladder cancer are:

  • Stage I. Cancer at this stage occurs in the bladder's inner lining but hasn't invaded the muscular bladder wall.
  • Stage II. At this stage, cancer has invaded the muscular bladder wall but is still confined to the bladder.
  • Stage III. The cancer cells have spread through the bladder wall to surrounding tissue.
  • Stage IV. By this stage, cancer cells may have spread to the lymph nodes and other organs, such as your bones, liver or lungs.

Bladder cancer grade

Bladder cancer tumors are further classified based on how the cancer cells appear when viewed through a microscope. This is known as tumor grade, and your doctor may describe bladder cancer as either low grade or high grade:

  • Low-grade bladder tumor. This type of tumor has cells that are closer in appearance and organization to normal cells (well-differentiated). A low-grade tumor usually grows more slowly and is less likely to invade the muscular wall of the bladder than is a high-grade tumor.
  • High-grade bladder tumor. This type of tumor has cells that are abnormal-looking and that lack any resemblance to normal-appearing tissues (poorly differentiated). A high-grade tumor tends to grow more aggressively than a low-grade tumor and may be more likely to spread to the muscular wall of the bladder and other tissues and organs.
Female cystoscopy

Cystoscopy allows your doctor to view your lower urinary tract to look for abnormalities, such as a bladder stone. Surgical tools can be passed through the cystoscope to treat certain urinary tract conditions.

Female cystoscopy

Cystoscopy allows your doctor to view your lower urinary tract to look for abnormalities, such as a bladder stone. Surgical tools can be passed through the cystoscope to treat certain urinary tract conditions.

Cystoscopy

Cystoscopy allows your doctor to view your lower urinary tract to look for abnormalities in your urethra and bladder. Surgical tools can be passed through the cystoscope to treat certain urinary tract conditions.

Treatment

Treatment options for bladder cancer depend on a number of factors, including the type of cancer, grade of the cancer and stage of the cancer, which are taken into consideration along with your overall health and your treatment preferences.

Bladder cancer treatment may include:

  • Surgery, to remove cancerous tissue
  • Chemotherapy in the bladder (intravesical chemotherapy), to treat tumors that are confined to the lining of the bladder but have a high risk of recurrence or progression to a higher stage
  • Reconstruction, to create a new way for urine to exit the body after bladder removal
  • Chemotherapy for the whole body (systemic chemotherapy), to increase the chance for a cure in a person having surgery to remove the bladder, or as a primary treatment in cases where surgery isn't an option
  • Radiation therapy, to destroy cancer cells, often as a primary treatment in cases where surgery isn't an option or isn't desired
  • Immunotherapy, to trigger the body's immune system to fight cancer cells, either in the bladder or throughout the body

A combination of treatment approaches may be recommended by your doctor and members of your care team.

Bladder cancer surgery

Approaches to bladder cancer surgery might include:

  • Transurethral resection of bladder tumor (TURBT). TURBT is a procedure to remove bladder cancers confined to the inner layers of the bladder, those which aren't yet muscle-invasive cancers. During the procedure, a surgeon passes a small wire loop through a cystoscope and into the bladder. The wire loop burns away cancer cells using an electric current. Alternatively, a high-energy laser may be used to destroy the cancer cells.

    TURBT is performed under regional anesthesia — where medication given numbs only the lower part of your body — or general anesthesia — where medication puts you to sleep during the surgery. Because doctors perform the procedure through the urethra, you won't have any cuts (incisions) in your abdomen.

    As part of the TURBT procedure, your doctor may recommend a one-time injection of cancer-killing medication (chemotherapy) into your bladder to destroy any remaining cancer cells and to prevent a tumor from coming back. The medication remains in your bladder for up to an hour and then is drained.

  • Cystectomy. Cystectomy is surgery to remove all or part of the bladder. During a partial cystectomy, your surgeon removes only the portion of the bladder that contains a single cancerous tumor. Partial cystectomy may only be an option if cancer is limited to one area of the bladder that can easily be removed without harming bladder function.

    A radical cystectomy is an operation to remove the entire bladder, part of the ureters and surrounding lymph nodes. In men, radical cystectomy typically includes removal of the prostate and seminal vesicles. In women, radical cystectomy also involves removal of the uterus, ovaries and part of the vagina.

    Radical cystectomy can be performed through a single incision on the lower portion of the belly or with multiple small incisions using robotic surgery. During robotic surgery, the surgeon sits at a nearby console and uses hand controls to precisely move robotic surgical instruments.

    Cystectomy carries a risk of infection and bleeding. In men, removal of the prostate and seminal vesicles may cause erectile dysfunction. But, your surgeon may be able to spare the nerves necessary for an erection. In women, removal of the ovaries causes infertility and premature menopause.

  • Neobladder reconstruction. After a radical cystectomy, your surgeon must create a new way for urine to leave your body (urinary diversion). One option for urinary diversion is neobladder reconstruction. Your surgeon creates a sphere-shaped reservoir out of a piece of your intestine. This reservoir, often called a neobladder, sits inside your body and is attached to your urethra. In most cases, the neobladder allows you to urinate normally. A small number of people with a neobladder have difficulty emptying the neobladder and may need to use a catheter periodically to drain all the urine from the neobladder.
  • Ileal conduit. For this type of urinary diversion, your surgeon creates a tube (ileal conduit) using a piece of your intestine. The tube runs from your ureters, which drain your kidneys, to the outside of your body, where urine empties into a pouch (urostomy bag) you wear on your abdomen.
  • Continent urinary reservoir. During this type of urinary diversion procedure, your surgeon uses a section of intestine to create a small pouch (reservoir) to hold urine, located inside your body. You drain urine from the reservoir through an opening in your abdomen using a catheter a few times each day.

Chemotherapy

Chemotherapy uses drugs to kill cancer cells. Chemotherapy treatment for bladder cancer usually involves two or more chemotherapy drugs used in combination.

Chemotherapy drugs can be given:

  • Through a vein in your arm (intravenously)
  • Via a tube passed through your urethra directly to your bladder (intravesical therapy)

Chemotherapy is frequently used before bladder removal surgery to increase the chances of curing the cancer. Chemotherapy may also be used to kill cancer cells that might remain after surgery. Chemotherapy is sometimes combined with radiation therapy in very select cases as an alternative to surgery.

Intravesical chemotherapy may be the primary treatment for superficial bladder cancer, where the cancer cells affect only the lining of the bladder and not the deeper muscle tissue. Or sometimes immunotherapy may be administered as intravesical therapy for superficial bladder cancer.

Radiation therapy

Radiation therapy uses high-energy beams aimed at your cancer to destroy the cancer cells. Radiation therapy for bladder cancer usually is delivered from a machine that moves around your body, directing the energy beams to precise points.

In select cases, radiation therapy is sometimes combined with chemotherapy as an alternative to surgery or when surgery isn't an option.

Immunotherapy

Immunotherapy, also called biological therapy, works by signaling your body's immune system to help fight cancer cells.

Immunotherapy for bladder cancer often is administered through the urethra and directly into the bladder (intravesical therapy). One such immunotherapy drug used to treat bladder cancer is Bacillus Calmette-Guerin (BCG), which is a vaccine used to protect against tuberculosis. Another immunotherapy drug is a synthetic version of interferon, which is a protein your immune system makes to help fight infections. The synthetic version, called interferon alfa-2b (Intron A), is sometimes used in combination with BCG.

Atezolizumab (Tecentriq) is a new immunotherapy option for locally advanced or metastatic bladder cancer that didn't respond to or got worse after chemotherapy. An intravenous (IV) medication, the drug works by triggering the body's immune system to attack the cancerous tumor. Atezolizumab is also being studied as a possible first line therapy for people with bladder cancer who aren't eligible for chemotherapy.

Bladder preservation

Using a three-prong treatment approach may preserve the bladder in certain cases of muscle-invasive disease. Known as trimodality therapy, the treatment approach includes TURBT, chemotherapy and radiation therapy.

First, your surgeon performs a TURBT procedure to remove as much cancerous tissue as possible from your bladder, while maintaining bladder function. After TURBT, you undergo a regimen of chemotherapy along with radiation therapy, which both take place during the first several weeks after surgery.

If, after trying trimodality therapy, not all of the cancer is gone or you have a recurrence of muscle-invasive cancer, your surgeon may recommend a radical cystectomy.

Upper urinary tract disease

The same kind of cancer (urothelial cancer) that causes the majority of bladder cancers can also occur in the upper urinary tract, affecting:

  • The thin tubes that drain urine from your kidneys to your bladder (ureters)
  • The area within your kidney where urine collects before emptying into a ureter (renal pelvis)
  • Other urinary tract structures deep within the kidney where the process of producing urine begins

Similar to treatment for bladder cancer, treatment of upper urinary tract cancer depends on a lot of factors, such as tumor size, tumor location, your overall health and your preferences.

Upper urinary tract cancer generally involves surgery to remove the cancer, along with chemotherapy or radiation therapy as follow-up treatments to kill any remaining cancer cells and to prevent recurrence.

Surgery might leave you with only one functioning kidney, if one of your kidneys needs to be removed. If that happens, your doctor will likely recommend regular testing of your kidney function to monitor how well your remaining kidney is doing.

After bladder cancer treatment

Bladder cancer may recur. Because of this, people with bladder cancer need follow-up testing for years after successful treatment. What tests you'll have and how often depends on your type of bladder cancer and how it was treated, among other factors.

Ask your doctor to create a follow-up plan for you. In general, doctors recommend a test to examine the inside of your urethra and bladder (cystoscopy) every three to six months for the first few years after bladder cancer treatment. After a few years of surveillance without detecting cancer recurrence, you may need a cystoscopy exam only once a year. Your doctor may recommend other tests at regular intervals as well.

People with aggressive cancers may undergo more-frequent testing. Those with less aggressive cancers may undergo testing less often.

Related video

Neobladder reconstruction

During neobladder surgery, your surgeon takes out your existing bladder and forms an internal pouch from part of your intestine. The pouch, called a neobladder, stores your urine.

Neobladder reconstruction

During neobladder surgery, your surgeon takes out your existing bladder and forms an internal pouch from part of your intestine. The pouch, called a neobladder, stores your urine.

Ileal conduit

During an ileal conduit procedure, your surgeon creates a new tube from a piece of intestine that allows your kidneys to drain and urine to exit the body through a small opening called a stoma.

Coping and support

Living with the concern that your bladder cancer may recur can leave you feeling as if you have little control over your future. But while there's no way to ensure that your bladder cancer won't recur, you can take steps to manage the stress.

Over time you'll find what works for you, but until then, you might:

  • Have a schedule of follow-up tests and go to each appointment. When you finish bladder cancer treatment, ask your doctor to create a personalized schedule of follow-up tests. Before each follow-up cystoscopy exam, expect to have some anxiety. You may fear that cancer has come back or worry about the uncomfortable exam. But don't let this stop you from going to your appointment. Instead, plan ways to cope with your concerns. Write your thoughts in a journal, talk with a friend or use relaxation techniques, such as meditation.
  • Take care of yourself so that you're ready to fight cancer if it comes back. Take care of yourself by adjusting your diet to include plenty of fruits, vegetables and whole grains. Exercise for at least 30 minutes most days of the week. Get enough sleep so that you wake feeling rested.
  • Talk with other bladder cancer survivors. Connect with bladder cancer survivors who are experiencing the same fears you're feeling. Contact your local chapter of the American Cancer Society to ask about support groups in your area.

Preparing for an appointment

Start by seeing your family doctor or a primary doctor if you have any signs or symptoms that worry you. Your doctor may suggest tests and procedures to investigate your signs and symptoms.

If your doctor suspects you may have bladder cancer, you may be referred to a doctor who specializes in treating diseases and conditions of the urinary tract (urologist). In some cases, you may be referred to other specialists, such as doctors who treat cancer (oncologists).

Because there's often a lot of ground to cover during the appointment, it's a good idea to be well-prepared. Here's some information to help you get ready, and what to expect from your doctor.

What you can do

  • Be aware of any pre-appointment restrictions. When you make the appointment, ask if there's anything you need to do in advance, such as restrict your diet.
  • Write down any symptoms you're experiencing, including any that seem unrelated to the reason for which you scheduled the appointment.
  • Make a note of key personal information, including things like recent life changes, or major stresses.
  • Make a list of all medications, vitamins or supplements that you're taking along with dosages.
  • Consider taking a family member or friend along. Sometimes, it's difficult to remember all of the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.
  • Write down a list of questions to ask your doctor.

Preparing a list of questions can help you make the most of your time with your doctor. For bladder cancer, some basic questions to ask include:

  • Do I have bladder cancer or could my symptoms be caused by another condition?
  • What is the stage of my cancer?
  • Will I need any additional tests?
  • What are my treatment options?
  • Can any treatments cure my bladder cancer?
  • What are the potential risks of each treatment?
  • Is there one treatment you feel is best for me?
  • Should I see a specialist? What will that cost, and will my insurance cover it?
  • Is there a generic alternative to the medicine you're prescribing me?
  • Are there brochures or other printed material that I can take with me? What websites do you recommend?
  • What will determine whether I should plan for a follow-up visit?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask other questions that occur to you.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may allow time later to cover other points you want to address. Your doctor may ask:

  • When did you first begin experiencing symptoms?
  • Have your symptoms been continuous or occasional?
  • How severe are your symptoms?
  • What, if anything, seems to improve your symptoms?
  • What, if anything, appears to worsen your symptoms?

Last updated: June 23rd, 2017

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