Bladder cancer

Bladder cancer is where a growth of abnormal tissue, known as a tumour, develops in the bladder lining. In some cases, the tumour spreads into the bladder muscle.

The most common symptom of bladder cancer is blood in your which is usually painless.

If you notice blood in your urine, even if it comes and goes, you should visit your GP, so the cause can be investigated.

Blood in your urine is the most common symptom of bladder cancer.

The medical name for this is haematuria and it's usually painless. You may notice streaks of blood in your urine or the blood may turn your urine brown. The blood isn't always noticeable and it may come and go.

Less common symptoms of bladder cancer include:

• a need to urinate on a more frequent basis
• sudden urges to urinate
• a burning sensation when passing urine

If bladder cancer reaches an advanced stage and begins to spread, symptoms can include:

• pelvic pain
• bone pain
• unintentional weight loss 
• swelling of the legs

When to seek medical advice

If you ever have blood in your urine – even if it comes and goes – you should visit your GP, so the cause can be investigated.

Having blood in your urine doesn't mean you definitely have bladder cancer. There are other, more common, causes including:

• a  urinary track infection, such as cystitis
  
• a  kidney infection
  
•  kidney stones
  
• urethritis
  
• an enlarged prostrate glands in men

Types of bladder cancer

Once diagnosed, bladder cancer can be classified by how far it has spread. 

If the cancerous cells are contained inside the lining of the bladder, doctors describe it as non-muscle-invasive bladder cancer. This is the most common type of bladder cancer. Most people don't die as a result of this type of bladder cancer.

When the cancerous cells spread beyond the lining, into the surrounding bladder muscle, it's referred to as muscle-invasive bladder cancer. This is less common, but has a higher chance of spreading to other parts of the body.

If bladder cancer has spread to other parts of the body, it's known as advanced or metastatic bladder cancer.

Diagnosis - Bladder cancer

If you have symptoms of bladder cancer, such as blood in your urine, you should see your GP.

Your GP may ask about your symptoms, family history and whether you've been exposed to any possible causes of bladder cancer, such as smoking.

In some cases, your GP may request a urine sample, so it can be tested in a laboratory for traces of blood, bacteria or abnormal cells.

Your GP may also carry out a physical examination of your rectum and vagina, as bladder cancer sometimes causes a noticeable lump that presses against them.

If your doctor suspects bladder cancer, you'll be referred to a hospital for further tests.

At the hospital

Some hospitals have specialist clinics for people with blood in there urine (haematuria) while others have specialist urology departments for people with urinary tract problems.

Cystoscopy

If you're referred to a hospital specialist and they think you might have bladder cancer, you should first be offered a cytoscopy

This procedure allows the specialist to examine the inside of your bladder by passing a cystoscope through your urethra (the tube through which you urinate). A cystoscope is a thin tube with a camera and light at the end.

Before having a cystoscopy, a local anesthtetic gel is applied to your urethra (the tube through which you urinate) so you don't feel any pain. The gel also helps the cystoscope to pass into the urethra more easily.

The procedure usually takes about 5 minutes.

Imaging scans

You may be offered a CTscans or an  MRI if the specialist feels they need a more detailed picture of your bladder.

An intravenous (IV) urogram may also be used to look at your whole urinary system before or after treatment for bladder cancer.

During this procedure, dye is injected into your bloodstream and X-rays are used to study it as it passes through your urinary system.

Transurethral resection of a bladder tumour (TURBT)

If abnormalities are found in your bladder during a cystoscopy, you should be offered an operation known as TURBT. This is so any abnormal areas of tissue can be removed and tested for cancer (a biopsy).

TURBT is carried out under general anaesthetic.

Sometimes, a sample of the muscle wall of your bladder is also taken to check whether the cancer has spread, but this may be a separate operation within 6 weeks of the first biopsy

You should also be offered a dose of chemotherapy after the operation. This may help to prevent the bladder cancer returning, if the removed cells are found to be cancerous.

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Staging and grading

Once these tests have been completed, it should be possible to tell you the grade of the cancer and what stage it is.

Staging is a measurement of how far the cancer has spread. Lower-stage cancers are smaller and have a better chance of successful treatment.

Grading is a measurement of how likely a cancer is to spread. The grade of a cancer is usually described using a number system ranging from G1 to G3. High-grade cancers are more likely to spread than low-grade cancers. 

The most widely used staging system for bladder cancer is known as the TNM system, where:

• T stands for how far into the bladder the tumour has grown
• N stands for whether the cancer has spread into nearby lymph nodes
• M stands for whether the cancer has spread into another part of the body (metastasis ), such as the lungs

T stages

The T staging system is as follows:

• TIS or CIS (carcinoma in situ) – a very early high-grade cancer confined to the innermost layer of the bladder lining
• Ta – the cancer is just in the innermost layer of the bladder lining
• T1 – the cancerous cells have started to grow into the connective tissue beyond the bladder lining

Bladder cancer up to the T1 stage is usually called early bladder cancer or non-muscle-invasive bladder cancer.

If the tumour grows larger than this, it's usually called muscle-invasive bladder cancer and is categorised as:

• T2 – the cancer has grown through the connective tissue, into the bladder muscle
• T3 – the cancer has grown through the layer of muscles, into the surrounding layer of fat

If the tumour grows larger than the T3 stage, it's considered to be advanced bladder cancer and is categorised as:

• T4 – the cancer has spread outside the bladder, into surrounding organs

N stages

The N staging system is as follows:

• N0 – there are no cancerous cells in any of your lymph nodes
• N1 – there are cancerous cells in just one of your lymph nodes in your pelvis
• N2 – there are cancerous cells in two or more lymph nodes in your pelvis
• N3 – there are cancerous cells in one or more of your lymph nodes (known as common iliac nodes) deep in your pelvis

M stages

There are only two options in the M system:

• M0 – where the cancer hasn't spread to another part of the body
• M1 – where the cancer has spread to another part of the body, such as the bones, lungs or liver

The TNM system can be difficult to understand, so don't be afraid to ask your care team questions about your test results and what they mean for your treatment and outlook.

Why does bladder cancer happen?

Most cases of bladder cancer appear to be caused by exposure to harmful substances, which lead to abnormal changes in the bladder's cells over many years. 

Tobacco smoke is a common cause and it's estimated that more than 1 in 3 cases of bladder cancer are caused by smoking.

Contact with certain chemicals previously used in manufacturing is also known to cause bladder cancer. However, these substances have since been banned.

Treating bladder cancer

In cases of non-muscle-invasive bladder cancer, it's usually possible to remove the cancerous cells while leaving the rest of the bladder intact.

This is done using a surgical technique called transurethral resection of a bladder tumour (TURBT). This is followed by a dose of chemotherapy medication directly into the bladder, to reduce the risk of the cancer returning.

In cases with a higher risk of recurrence, medicine known as Bacillus Calmette-Guérin (BCG) may be injected into the bladder to reduce the risk of the cancer returning.

Treatment for high-risk non-muscle-invasive bladder cancer, or muscle-invasive bladder cancer may involve surgically removing the bladder in an operation known as a cystectomy.

Most patients will have a choice of either surgery or a course of radiotherapy

When the bladder is removed, you'll need another way of collecting your urine. Possible options include making an opening in the abdomen so urine can be passed into an external bag, or constructing a new bladder out of a section of bowel. This will be done at the same time as a cystectomy.

After treatment for all types of bladder cancer, you'll have regular follow-up tests to check for signs of recurrence.

Treatment - Bladder cancer

The treatment options for bladder cancer largely depend on how advanced the cancer is.

Treatments usually differ between early stage, non-muscle-invasive bladder cancer and more advanced muscle-invasive bladder cancer.

Your medical team

All hospitals use multidisciplinary teams to treat bladder cancer. These are teams of specialists that work together to make decisions about the best way to proceed with your treatment.

Members of your team may include:

• a urologist – a surgeon specialising in treating conditions affecting the urinary tract
• a clinical oncologist – a specialist in chemotherapy and radiotherapy
• a pathologist – a specialist in diseased tissue
• a radiologist – a specialist in detecting disease using imaging techniques

You should be given the contact details for a clinical nurse specialist, who will be in contact with all members of your medical team. They'll be able to answer questions and support you throughout your treatment.

Deciding what treatment is best for you can be difficult. Your medical team will make recommendations, but remember that the final decision is yours. 

Before discussing your treatment options, you may find it useful to write a list of questions to ask your team.

Non-muscle-invasive bladder cancer

If you've been diagnosed with non-muscle-invasive bladder cancer (stages CIS, Ta and T1), your recommended treatment plan depends on the risk of the cancer returning or spreading beyond the lining of your bladder.

This risk is calculated using a series of factors, including:

• the number of tumours present in your bladder
• whether the tumours are larger than 3cm (1 inch) in diameter
• whether you've had bladder cancer before
• the grade of the cancer cells

These treatments are discussed in more detail below.

Low-risk

Low-risk non-muscle-invasive bladder cancer is treated with trans urethral resection of a bladder tumour (TURBT). This procedure may be performed during your first cystoscopy, when tissue samples are taken for testing

TURBT is carried out under general anaesthesis. The surgeon uses an instrument called a cystoscope to locate the visible tumours and cut them away from the lining of the bladder. The wounds are sealed (cauterised) using a mild electric current, and you may be given a catherato drain any blood or debris from your bladder over the next few days.

After surgery, you should be given a single dose of Chemotherapy, directly into your bladder, using a catheter. The chemotherapy solution is kept in your bladder for around an hour before being drained away.

Most people are able to leave hospital less than 48 hours after having TURBT and are able to resume normal physical activity within 2 weeks.

You should be offered follow-up appointments at 3 and 9 months to check your bladder, using a  cytoscopy. If your cancer returns after 6 months, and is small, you may be offered a treatment called figuration. This involves using an electric current to destroy the cancer cells.

Intermediate-risk

People with intermediate-risk non-muscle-invasive bladder cancer should be offered a course of at least 6 doses of chemotherapy. The liquid is placed directly into your bladder, using a catheter, and kept there for around an hour before being drained away.

You should be offered follow-up appointments at 3, 9 and 18 months, then once every year. At these appointments, your bladder will be checked using a cystoscopy. If your cancer returns within 5 years, you'll be referred back to a specialist urology team.

Some residue of the chemotherapy medication may be left in your urine after treatment, which could severely irritate your skin. It helps if you urinate while sitting down and that you're careful not to splash yourself or the toilet seat. After passing urine, wash the skin around your genitals with soap and water.

If you're sexually active, it's important to use a barrier method of contaception, such as a condom. This is because the medication may be present in your semen or vaginal fluids, which can cause irritation.

You also shouldn't try to get pregnant or father a child while having chemotherapy for bladder cancer, as the medication can increase the risk of having a child with birth defects.

High-risk

People with high-risk non-muscle-invasive bladder cancer should be offered a second TURBT operation, within 6 weeks of the initial investigation . A CT scan or an MRI scan may also be required.

Your urologist and clinical nurse specialist will discuss your treatment options with you, which will either be:

• a course of Bacillus Calmette-Guérin (BCG) treatment – using a variant of the BCG vaccine
• an operation to remove your bladder (cystectomy)

The BCG vaccine is passed into your bladder through a catheter and left for 2 hours before being drained away. Most people require weekly treatments over a 6-week period. Common side effects of BCG include:

• a frequent need to urinate
• pain when urinating
• blood in your urine (haematuria)
• flu-like symptoms, such as tiredness, fever and aching
• urinary tract infections

If BCG treatment doesn't work, or the side effects are too strong, you'll be referred back to a specialist urology team.

You should be offered follow-up appointments every 3 months for the first 2 years, then every 6 months for the next 2 years, then once a year. At these appointments, your bladder will be checked using a cytoscopy.

If you decide to have a cystectomy, your surgeon will need to create an alternative way for urine to leave your body (urinary diversion). Your clinical nurse specialist can discuss your options for the procedure and how the urinary diversion will be created.

After having a cystectomy, you should be offered follow-up appointments including a CT scan at 6 and 12 months, and blood tests once a year. Men require an appointment to check their urethra once a year for 5 years.

Muscle-invasive bladder cancer

The recommended treatment plan for muscle-invasive bladder cancer depends on how far the cancer has spread. With T2 and T3 bladder cancer, treatment aims to cure the condition if possible, or at least control it for a long time.

Your urologist, oncologist and clinical nurse specialist will discuss your treatment options with you, which will either be:

• an operation to remove your bladder (cystectomy)
• radio therapy with a radiosensitiser

Your oncologist should also discuss the possibility of having chemotherapy before either of these treatments (neoadjuvant therapy), if it's suitable for you.

Radiotherapy with a radiosensitiser

Radiotherapy is given by a machine that beams the radiation at the bladder (external radiotherapy). Sessions are usually given on a daily basis for 5 days a week over the course of 4 to 7 weeks. Each session lasts for about 10 to 15 minutes.

A radiosensitiser should also be given alongside radiotherapy for muscle-invasive bladder cancer. This is a medicine which affects the cells of a tumour, to enhance the effect of radiotherapy. It has a much smaller effect on normal tissue.

As well as destroying cancerous cells, radiotherapy can also damage healthy cells, which means it can cause a number of side effects. These include:

• diahorea
  
• inflamation of the bladder cytitis
  
• tightening of the vagina (in women), which can make having sex painful
• erectile dysfunction (in men)
• loss of pubic hair
• infertility
• tiredness
• difficulty passing urine

Most of these side effects should pass a few weeks after your treatment finishes, although there's a small chance they'll be permanent.

Having radiotherapy directed at your pelvis usually means you'll be infertile for the rest of your life. However, most people treated for bladder cancer are too old to have children, so this isn't usually a problem.

After having radiotherapy for bladder cancer, you should be offered follow-up appointments every 3 months for the first 2 years, then every 6 months for the next 2 years, and every year after that. At these appointments, your bladder will be checked using a cytoscopy. 

You may also be offered CT scans of your chest, abdomen and pelvis after 6 months, 1 year and 2 years. A CT scan of your urinary tract may be offered every year for 5 years.

Surgery or radiotherapy?

Your medical team may recommend a specific treatment because of your individual circumstances.

For example, someone with a small bladder or many existing urinary symptoms is better suited to surgery. Someone who has a single bladder tumour with normal bladder function is better suited for treatments that preserve the bladder.

However, your input is also important, so you should discuss which treatment is best for you with your medical team.

There are pros and cons of both surgery and radiotherapy.

The pros of having a radical cystectomy include:

• treatment is carried out in one go
• you won't need regular cystoscopies after treatment, although other less invasive tests may be needed

The cons of having a radical cystectomy include:

• it can take up to 3 months to fully recover
• a risk of general surgical complications, such as pain, infection and bleeding
• a risk of complications from the use of general anaesthetic
• an alternative way of passing urine out of your body needs to be created, which may involve an external bag
• a high risk of erectile dysfunction in men (estimated at around 90%) as a result of nerve damage
• after surgery, some women may find sex uncomfortable, as their vagina may be smaller
• a small chance of a fatal complication, such as aheart attack, stroke or Deep Vein Thrombosis (DVT).
  

The pros of having radiotherapy include:

• there's no need to have surgery, which is often an important consideration for people in poor health
• your bladder function may not be affected, as your bladder isn't removed
• there's less chance of causing erectile dysfunction (around 30%)

The cons of having radiotherapy include:

• you'll require regular sessions of radiotherapy for 4 to 7 weeks
• short-term side effects are common, such as diarrhoea, tiredness and inflammation of the bladder (cystitis)
• a small chance of permanently damaging the bladder, which could lead to problems urinating
• women may experience a narrowed vagina, making sex difficult and uncomfortable

Chemotherapy

In some cases, chemotherapy may be used during treatment for muscle-invasive bladder cancer. Instead of medication being put directly into your bladder, it's put into a vein in your arm. This is called intravenous chemotherapy and can be used:

• before radiotherapy and surgery to shrink the size of any tumours
• in combination with radiotherapy before surgery (chemoradiation)
• to slow the spread of incurable advanced bladder cancer (palliative chemotherapy)

There isn't enough evidence to say whether chemotherapy is an effective treatment when it's given after surgery to prevent the cancer returning. It's usually only used this way as part of a clinical trial See clinical trials for more information.

Chemotherapy is usually given once a week for 2 weeks followed by a week off. This cycle will be repeated for a few months.

As the chemotherapy medication is being injected into your blood, you'll experience a wider range of side effects than if you were having chemotherapy directly into the bladder. These side effects should stop after the treatment has finished.

Chemotherapy weakens your immune system, making you more vulnerable to infection. It's important to report any symptoms of a potential infection, such as a high temperature, persistent cough or reddening of the skin, to your medical team. Avoid close contact with people who are known to have an infection.

Other side effects of chemotherapy can include:

• nausea
• vomiting
• hair loss
  
• lack of appetite
• tiredness

Advanced or metastatic bladder cancer

The recommended treatment plan for locally advanced or metastatic bladder cancer depends on how far the cancer has spread. Your oncologist should discuss your treatment options with you, which may include:

• chemotherapy
• immunotherapy
• treatments to relieve cancer symptoms

Chemotherapy

If you receive a course of chemotherapy, you'll be given a combination of drugs to help relieve the side effects of treatment. Treatment may be stopped if chemotherapy isn't helping, or a second course may be offered.

Immunotherapy

This medicine is for adults with advanced or metastatic bladder cancer. It works by helping the immune system recognise and attack cancer cells.

Relieving cancer symptoms

You may be offered treatment to relieve any cancer symptoms. This may include:

• radiotherapy to treat painful urination, blood in urine, frequently needing to urinate or pain in your pelvic area
• treatment to drain your kidneys, if they become blocked and cause lower back pain

Palliative or supportive care

If your cancer is at an advanced stage and can't be cured, your medical team should discuss how the cancer will progress and which treatments are available to ease the symptoms. 

You can be referred to a palliative care team, who can provide support and practical help, including pain relief.

Who is affected?

About 10,000 people are diagnosed with bladder cancer every year and it's the tenth most common cancer in the UK.

The condition is more common in older adults, with most new cases diagnosed in people aged 60 and above.

Bladder cancer is also more common in men than in women, possibly because in the past, men were more likely to smoke and work in the manufacturing industry.

Next review due: 10 May 2021