Bladder cancer

The bladder is a hollow, muscular organ that collects and stores pee (urine).

In the UK, over 10,000 people are diagnosed with bladder cancer each year. The real number is likely to be higher, because of the way this information is collected.

Bladder cancer is often described using the terms below. They tell you whether the cancer is only in the bladder lining or has spread through the wall of the bladder.

In non-muscle-invasive bladder cancer, the cancer cells are in the inner lining of the bladder, or in the connective tissue that surrounds that lining. They haven't spread into the muscle layer.

This type of cancer can be mushroom shaped, and doctors call that a papillary tumour or Ta. It can also be flat and red, which is called carcinoma in situ (CIS). Some people have both a papillary tumour and CIS.

If the cancer cells are in the connective tissue, this is called T1.

Muscle-invasive bladder cancer (MIBC) is when the cancer has grown into the muscle layer of the bladder, or has gone right through the muscle into the fat layer. It hasn't spread outside the bladder.

Locally advanced bladder cancer means the cancer has spread outside the bladder into:

• nearby tissues
• prostate
• vagina
• ovaries
• womb
• back passage (rectum)

It may also be in lymph nodes in the pelvis, near the bladder.

Advanced bladder cancer means the cancer has spread to other parts of the body.

Bladder cancer comes in different types, and each one is named after the cell it started in.

The most common type is urothelial cancer. You may also hear it called urothelial carcinoma or transitional cell carcinoma (TCC). It starts in cells called urothelial or transitional cells, which make up the bladder lining.

Less common types of bladder cancer include:

• squamous cell carcinoma
• adenocarcinoma
• small cell bladder cancer

These start from other types of cells in the bladder lining. They're usually muscle-invasive bladder cancers.

The most common symptom of bladder cancer is blood in the pee (urine). Doctors call this haematuria. Sometimes you can see the blood yourself, which is called visible blood. Other times it only shows up when a doctor or nurse tests your urine with a dipstick, and that is called non-visible blood.

Many people with blood in their pee don't have bladder cancer. Still, if you notice any symptoms, get them checked by your doctor. The earlier bladder cancer is diagnosed, the more likely it is to be cured.

Other symptoms of bladder cancer, especially in people aged 45 or older, can include:

• problems with passing urine, like pain when you pee or having to pee more often, which isn't settling after treatment or keeps coming back
• tiredness or fatigue
• losing weight without trying
• fever or high temperature
• back pain, typically to the side of the spine between the ribs and the hip bones

In most cases these symptoms point to something other than cancer, like a urinary tract infection (UTI). But if your symptoms are unusual and don't go away, it's always best to see your doctor as soon as possible and get checked.

Macmillan Cancer Support has more information about the signs and symptoms of bladder cancer.

If you have any symptoms, see a doctor as soon as possible so you get checked early. The doctor can test your pee (urine) for blood and send it to a lab to check for a urine infection (UTI). They may also send the pee away to be tested for cancer cells.

They may examine you internally, because the bladder sits close to the bowel, and the prostate or womb. The doctor puts a gloved finger into the back passage (rectum) or vagina and feels for any obvious changes. This is called an internal examination.

If your doctor thinks you may have cancer, or isn't sure what's causing your symptoms, they'll refer you to a urologist. That's a doctor who treats bladder and kidney problems. You may instead see a nurse called a urology nurse specialist.

If tests or symptoms suggest you could have bladder cancer, your doctor will refer you urgently. This means you should get a specialist appointment as soon as possible.

Most people see the nurse or doctor at a haematuria clinic or in a hospital's urology department. They may test your pee again and give you another internal examination. If they think you need more tests, they'll arrange them, and you'll usually have most of these on the same day.

A cystoscopy is the main test doctors use to check for signs of bladder cancer inside the bladder.

The test uses a cystoscope, which is a thin tube with a camera and a light on the end. A doctor or specialist nurse passes it in and uses it to look at the inside of your bladder.

There are different types of cystoscopy. Your doctor or nurse will explain which type you need.

If you have bladder cancer, your doctor may ask for blood tests. These show how well your kidneys and liver are working, and they count the blood cells in your blood.

Your doctor may send a sample of your urine (pee) to be checked for cancer cells. The sample can also be tested for certain substances that are found in bladder cancer. This second kind of test is called molecular testing.

An ultrasound scan uses sound waves to build up a picture of the inside of your body. For bladder cancer, it can show anything unusual in the urinary system.

You'll be asked to drink plenty of fluids so the bladder can be seen more easily. This may be uncomfortable, but you can pee (pass urine) as soon as the scan is over. If you have any concerns about this, talk to the person doing the scan.

For the scan, you'll lie on your back, and the person doing it will try to make you comfortable. They'll spread a cold gel over your tummy (abdomen) and pass a small device that makes sound waves over the area. A computer then turns the sound waves into a picture.

The scan is painless and takes about 15 to 20 minutes.

A CT urogram is a scan that takes a series of X-rays and puts them together to build a 3D picture of your bladder, ureters and kidneys.

A CT scan takes a series of X-rays and puts them together to build a 3D picture of the inside of your body.

An MRI scan uses magnetism to build up a detailed picture of areas of the body.

You may have a PET scan and a CT scan done together, and this is called a PET-CT scan.

A PET scan uses a low dose of radiation to check the activity of cells in different parts of your body. It can give more detailed information about cancer, or about abnormal areas that were seen on X-rays, CT scans or MRI scans.

Waiting for test results can be a difficult time, and support may help.

The stage of a bladder cancer describes where the cancer has been found and any other places it has spread to.

Grading describes how the cancer cells look under the microscope compared with normal cells.

Knowing the stage and grade supports your doctors when they plan the best treatment for you.

In non-muscle-invasive bladder cancer, the cancer cells are in the inner lining of the bladder, or in the connective tissue that surrounds that lining. They haven't spread into the muscle layer below.

Treatment may include the following.

A TURBT, short for transurethral resection of the bladder tumour, is an operation to remove bladder cancer from the inside of the bladder. It's the main treatment for non-muscle invasive bladder cancer.

Chemotherapy means using anti-cancer (cytotoxic) drugs to destroy cancer cells. In intravesical chemotherapy for bladder cancer, the drugs are given straight into the bladder through a tube called a catheter.

BCG is short for Bacillus Calmette-Guérin. It's a type of immunotherapy drug, which means it uses the body's immune system to find and attack cancer cells.

For bladder cancer, BCG is given directly into the bladder through a tube called a catheter (intravesical).

Some people may have a cystectomy, which is surgery to remove the bladder. You may be asked to think about this if you have:

• a high-risk cancer
• a cancer that keeps coming back and treatments are not working

Heated intravesical chemotherapy means the chemotherapy given into the bladder is warmed first. This may help it work better in bladder cancer.

In electromotive intravesical chemotherapy for bladder cancer, a small electrical current is passed into the bladder at the same time as the chemotherapy. This may help the chemotherapy work better.

Tumour ablation uses a laser, which is an infra-red light, during a cystoscopy. The light burns away any areas of cancer in the bladder.

New treatments are being developed for non-muscle-invasive bladder cancer. Some of them may be offered as part of a clinical trial. Immunotherapy is one of these.

Muscle-invasive bladder cancer means the cancer has spread into or through the muscle layer of the bladder wall. Treatment usually tries to cure the cancer, and it uses one of the following.

Cystectomy is an operation to remove the bladder. The surgeon then makes a new way for you to pass urine (pee), which is called a urinary diversion.

You may also have chemotherapy into a vein before or after the operation. These anti-cancer drugs help reduce the risk of the cancer coming back.

Radiotherapy uses high-energy rays to destroy cancer cells. In bladder cancer, radical radiotherapy means radiotherapy given together with other treatments, such as surgery or chemotherapy.

When bladder cancer is called locally advanced, it means the cancer has spread outside the bladder into nearby areas of the body.

The best treatment depends on which areas are affected. Some people have treatment that aims to cure the cancer. Others have treatment that aims to control the cancer and any symptoms it's causing.

Advanced bladder cancer is cancer that has spread from the bladder to other parts of the body. You may also hear doctors call it metastatic bladder cancer.

People with advanced bladder cancer, and some people whose cancer is locally advanced, have treatments that aim to:

• shrink or control the cancer and help you live longer
• reduce your symptoms and improve quality of life

This is called supportive treatment or palliative treatment. It may include the following.

Chemotherapy for bladder cancer uses anti-cancer medicines, called cytotoxic drugs, to destroy cancer cells.

Immunotherapy drugs use your immune system to find and attack bladder cancer cells.

Radiotherapy uses high-energy rays to destroy cancer cells. Your doctor may suggest it to treat bladder symptoms such as bleeding. It may also be given if bladder cancer has spread to the bones.

Medicines called bisphosphonates, or a medicine called denosumab, can help strengthen the bones and may ease bone pain.

Sometimes bladder cancer blocks the ureter, which is the tube that runs from the kidney to the bladder. If this happens, your doctor may suggest an operation to put a small tube, called a stent, into the ureter to open it up. This is known as a ureteric stent.

A nephrostomy is a tube that lets urine drain from the kidney through an opening in the skin on your back. You may need one if bladder cancer has blocked the ureter, the tube between the kidney and the bladder. The nephrostomy tube is attached to a drainage bag outside your body.

You may have some treatments as part of a clinical trial. Your doctor will explain if this is available.

Macmillan Cancer Support has more information on treatment for bladder cancer and on treatment decisions for bladder cancer.

Once your treatment for bladder cancer is over, you'll see your cancer doctor or nurse for regular follow-up appointments. To start with, these are usually every few months.

If you have any problems or notice new symptoms between appointments, tell your doctor or nurse as soon as you can.

The test your doctor will rely on most during follow-up is a cystoscopy. How often you need one depends on the risk of the cancer coming back. Tumours that are high-risk or intermediate-risk need to be watched more closely than low-risk ones.

You may also have your urine (pee) checked for cancer cells. In the beginning, you will usually see your doctor every 3 to 6 months.

You may have scans to check for any sign of the muscle-invasive bladder cancer coming back. Your doctor or nurse will explain what type of scans you need and how often.

You'll have regular scans and blood tests to check your kidneys are working well, if you have a:

• urostomy
• continent urinary diversion
• bladder reconstruction

If you had a cystectomy but your urethra wasn't removed during surgery, there's a small risk that the cancer could come back there. You'll have tests every year to check the urethra. These are called urethroscopies, and they usually continue for 5 years.

If you had radiotherapy, you'll have regular cystoscopies. These matter because if the cancer comes back, you may be able to have surgery to treat it again.

The cystoscopies will be every 3 months at first, but less often over time. You'll have them for at least 5 years after treatment finishes.

You'll have regular appointments with your doctor or nurse so they can check how you are. They'll also help manage any symptoms the cancer causes. You may have tests and scans to keep an eye on the cancer.

You may also see a palliative care team. This is an expert team that helps manage symptoms, like pain or nausea.

Palliative care teams are based in hospitals, hospices or in the community. Your cancer doctor or nurse can give you more information.

Small changes, like eating well and keeping active, can improve your health and wellbeing and help your body recover. Even if you already live healthily, you may want to make some positive changes after treatment.

Some treatments for bladder cancer can cause ongoing side effects. These may include bladder or bowel changes, or problems with sexual wellbeing. Sometimes the side effects are long term.

Help and support are available, and there are usually things that can help you cope. If you have side effects or changes and need advice, talk to your cancer doctor, nurse or doctor.