Many of the symptoms of bladder cancer could easily be caused by other things, but doctors say it is important to consult them so that any cancer can be caught early.

Professor Nick James, a consultant oncologist at Birmingham City Hospital, some of whose work is funded by Cancer Research UK said that patients finding any blood in their urine need to be referred to a hospital clinic.

He said: “If the cancer is superficial, then long term survival is exceptional, but, considering how early it is normally found, if it is an invasive cancer, survival is surprisingly poor.”

Certainly if radical surgery has to be carried out, it can have highly inconvenient and lasting effects on the patient, and doctors will try to avoid this wherever possible.

Dr James stresses the importance of discussing other options, such as radiotherapy, before agreeing to an operation.

“I think it’s important that patients get the opportunity to discuss alternatives to surgery with an oncologist,” he said.

However, bladder cancer is overall considered one of the more surviveable cancers, with more than half of both men and women alive five years after diagnosis.

Most bladder cancers are what are called “transitional cell carcinomas”, which means they start in the cells which line the bladder.

Some are not detected until they spread through this lining into the muscle beyond which helps the bladder contract and push out urine.

Some common symptoms of bladder cancer include:

—      Blood in the urine

—      Pain during urination

—      Frequent urination, or wanting to pass water but being unable to do so

These are not definite signs that bladder cancer is present, and many symptoms like these can be explained by a simple infection, treatable with antibiotics.

Even if there is a tumour there which is causing pain, it could be benign rather than a malignant cancer.

To confirm or rule out cancer, the doctor will carry out a full physical examination, and probably a rectal exam using a gloved finger to check for unusual masses which might be a tumour.

Another method used by doctors is cytoscopy.

This involves inserting a very thin probe up the urethra - the tube through which urine is passed. This is an uncomfortable procedure but not usually painful.

The probe allows the doctor to look around for signs of disease, or another cause for the symptoms such as bladder stones.

The probe can also remove a tissue sample which can be removed and examined under a microscope for cancer cells.

If this confirms cancer, then further tests, such as CT scans, MRI, or other x-rays may be carried out to check the spread of the disease.

As with many other cancers, smokers appear to be at a higher risk of developing bladder cancer - two to three times more likely in fact.

In addition, scientists have found links with certain occupations and perhaps the chemicals used there.

Increased risk appears to affect the rubber, chemical and leather industries.

However, despite these discoveries, researchers do not know exactly why and how the disease first develops.

Treatment depends how far the cancer has spread.

If it is confined to the lining of the bladder, then a simple procedure called transurethral resection (TUR) can be carried out.

This is similar to cytoscopy, except the probe is used to burn away cancer cells with an electric current. This is normally carried out under anaesthetic.

The patient may have pain when passing water for a short time afterwards, and some blood in the urine.

However, if the cancer has spread into the bladder muscle, then a bigger operation may be needed.

If the cancer is not particularly fast-spreading and aggressive, and is confined to only one part of the bladder wall, then a partial or “segmental” cystectomy could be carried out.

This involves removing part of the bladder, and allows the patient to urinate normally once recovered.

However, if the cancer has spread more, “radical” cystectomy is carried out, and the entire bladder is taken out, along with any nearby organs that bladder cancer cells may have spread to.

In men, these can include the prostate - a gland near the testicles which makes a component of semen, and the seminal vesicles, the tubes which carry semen to the penis.

In women, the cancer may have spread to the womb, ovaries, and other parts of the reproductive system.

If the bladder has been removed, the patient no longer has anywhere to store the constant slow stream of urine coming from the kidneys.

The surgeon creates an opening in the patient’s side, which is called a stoma. This allows a bag to be attached to collect the urine.

A piece of the patient’s own small intestine can be used as the tube carrying the urine to the stoma.

Modern surgical techniques may allow a replacement bladder to be fashioned in some patients, giving back a degree of urinary control, and doctors are constantly improving these.

The doctor may also recommend radiotherapy either as the first treatment, or to try to kill any cancer cells which remain after surgery.

This is either targeted on the pelvic area, or the patient is given a radioactive implant which is placed directly into the bladder.

Chemotherapy can also be directly targeted at the bladder in some cases, which helps prevent some of the unpleasant side-effects, with drugs being pumped up a tube into the bladder.

However, if the cancer is widely spread, then standard chemotherapy may be used to try to kill lingering cancer cells.

Immunotherapy - harnessing the immune system to fight bladder cancer, is also widely used in some cases of superficial cancer.

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The wall of the bladder is lined with cells called transitional cells and squamous cells. More than 90 percent of bladder cancers begin in the transitional cells. This type of bladder cancer is called transitional cell carcinoma. About 8 percent of bladder cancer patients have squamous cell carcinomas.

Cancer only in cells in the lining of the bladder is called superficial bladder cancer. This type of bladder cancer often comes back after treatment, but it does not tend to progress. If the tumor recurs, the disease often recurs as another superficial cancer in the bladder. Cancer that begins as a superficial tumor may grow through the lining and into the muscular wall of the bladder. This is known as invasive cancer. Invasive cancer may extend through the bladder wall. It may grow into a nearby organ such as the uterus or vagina in women or the prostate gland in men. It also may spread to other parts of the body.

When bladder cancer spreads outside the bladder, cancer cells are often found in nearby lymph nodes. If the cancer has reached these nodes, cancer cells may have spread to other lymph nodes or other organs, such as the lungs, liver or bones.

When cancer spreads or metastasizes from its original place to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the primary tumor. For example, if bladder cancer spreads to the lungs, the cancer cells in the lungs are actually bladder cancer cells. The disease is metastatic bladder cancer, not lung cancer. It is treated as bladder cancer, not as lung cancer. Doctors sometimes call the new tumor “distant” disease.

Fortunately, the majority of bladder cancers do not grow rapidly and can be treated without major surgery. Thus, most patients with bladder cancer are not at risk of developing a cancer that will spread and become life threatening. Early detection is vital; it allows the prompt treatment that gives patients the best chance for a favorable outlook.

Common symptoms of bladder cancer include:

Blood in the urine, making the urine slightly rusty to deep red

Pain during urination

Frequent urination, or feeling the need to urinate without results

These symptoms are not sure signs of bladder cancer. Infections, benign tumors, bladder stones or other problems also can cause these symptoms.

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Description of Bladder Cancer

Bladder cancer is a disease in which cancer (malignant) cells are found in the bladder. The bladder, a hollow organ in the lower part of the abdomen, stores urine. It is shaped like a small balloon, and it has a muscular wall that allows it to get larger or smaller. Urine is the liquid waste that is made by the kidneys when they clean the blood. The urine passes from the two kidneys into the bladder through two tubes called ureters. When the bladder is emptied during urination, the urine goes from the bladder to the outside of the body through another tube called the urethra.

Like most cancers, cancer of the bladder is best treated when it is found (diagnosed) early. You should see your doctor if you have any of the following symptoms: blood in the urine (urine that looks bright red or rusty), pain when you urinate, passing urine often, or feeling like you need to urinate but nothing comes out.

If you have symptoms, your doctor may use several tests to see if you have cancer of the bladder. Your urine may be sent to a laboratory for tests to see if any cancer cells are present. The doctor may also do an internal examination by inserting gloved fingers into the vagina and/or rectum to feel for lumps. Your doctor may then order a special x-ray called an intravenous pyelogram (IVP). For this x-ray, a special dye containing iodine is given to you through a needle inserted into a vein. The dye then goes into the urine, making the bladder easier to see on the x-rays. You may feel warm as the dye is given.

Your doctor may also look directly into the bladder with a thin lighted tube called a cystoscope. The cystoscope is inserted into the bladder through the urethra. If tissue that is not normal is found, your doctor will need to cut out a small piece of this tissue and look at it under the microscope to see if there are any cancer cells. This procedure is called a biopsy. Other special x-rays may also be done to help diagnose cancer of the bladder.

Your chance of recovery (prognosis) and choice of treatment depend on the stage of your cancer (whether it is just in the lining of the bladder or has spread to other places in the body) and your general state of health.

Stages Of Cancer Of The Bladder

Once cancer of the bladder has been diagnosed, more tests will be done to find out if cancer cells have spread to other parts of the body (staging). To plan treatment, your doctor needs to know the stage of your disease. The following stages are used for cancer of the bladder:

Stage 0 Or Carcinoma In Situ Stage 0 is very early cancer. The cancer is found only on the inner lining of the bladder. After the cancer is taken out, no swelling or lumps are felt during an internal examination.

Stage I Cancer cells have spread a little deeper into the inner lining of the bladder but have not spread to the muscular wall of the bladder.

Stage II Cancer cells have spread to the inside lining of the muscles lining the bladder.

Stage III Cancer cells have spread throughout the muscular wall of the bladder, to the layer of tissue surrounding the bladder and/or to the nearby reproductive organs. Your doctor may feel swelling or lumps after you have had an operation to take out the cancer.

Stage IV Cancer cells have spread to the wall of the abdomen or pelvis or to the lymph nodes in the area. (Lymph nodes are small, bean-shaped structures that are found throughout the body; they produce and store infection-fighting cells.) The cancer may have also spread to lymph nodes and other parts of the body far away from the bladder.

Recurrent Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the original place or in another part of the body.

How Cancer Of The Bladder Is Treated

There are treatments for all patients with cancer of the bladder. Four kinds of treatment are used: surgery (taking out the cancer in an operation) radiation therapy (using high-dose x-rays or other high-energy rays to kill cancer cells and shrink tumors) chemotherapy (using drugs to kill cancer cells) biological therapy (using the body’s immune system to fight cancer).

A new type of treatment called photodynamic therapy is being tested in clinical trials.

Surgery is a common treatment for cancer of the bladder. Your doctor may take out the cancer using one of the following operations:

Transurethral resection is an operation that uses a cystoscope inserted into the bladder through the urethra. The doctor then uses a tool with a small wire loop on the end to remove the cancer or to burn the tumor away with high-energy electricity (fulguration).

Segmental cystectomy is an operation to take out the part of the bladder where the cancer is found. Because bladder cancer often occurs in more than one part of the bladder, this operation is used only in selected cases where the cancer is in one area.

Cystectomy is an operation to take out the bladder.

Radical cystectomy is an operation to take out the bladder and the tissue around it. In women, the uterus, ovaries, fallopian tubes, part of the vagina, and urethra are also removed. In men, the prostate and the glands that produce fluid that is part of the semen (seminal vesicles) are also removed, and the urethra may be removed as well. The lymph nodes in the pelvis may also be taken out (pelvic lymph node dissection).

Urinary diversion is an operation to make a way for urine to pass out of the body so that it does not go through the bladder. It is used to relieve bladder symptoms when the tumor has spread.

If your bladder is removed, your doctor will need to make a new way for you to store and pass urine. There are several ways to do this. Sometimes your doctor will use part of the small intestine to make a tube through which urine can pass out of the body through an opening (stoma) on the outside of the body. This procedure is sometimes called an ostomy or urostomy.

If you have an ostomy, you will need to wear a special bag to collect urine. This special bag, which sticks to the skin around the stoma with a special glue, can be thrown away after it is used. The bag does not show under clothing and most people take care of these bags themselves. The doctor may also use part of your small intestine to make a new storage pouch (a continent reservoir) inside the body where urine can collect. You would then need to use a tube (catheter) to drain the urine through the stoma. Newer methods use a part of the small intestine to make a new storage pouch that is connected to the remaining part of the urethra if it has not been removed. Urine then passes out of the body through the urethra, and a stoma is not necessary.

Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy may be taken by pill, or it may be put in the body through a needle inserted into a vein or muscle. Chemotherapy is called a systemic treatment because the drug enters the bloodstream, travels through the body, and can kill cancer cells outside the bladder. Chemotherapy may also be given in a fluid that is put into the bladder through a tube going through the urethra (intravesical chemotherapy).

If your doctor removes all the cancer that can be seen at the time of the operation, you may be given chemotherapy after surgery to kill any cancer cells that are left. Chemotherapy given after an operation to a person who has no cancer cells that can be seen is called adjuvant chemotherapy. For bladder cancer, chemotherapy is sometimes given before surgery to try to improve results or to preserve the bladder. Chemotherapy given in this manner is called neoadjuvant chemotherapy. Neoadjuvant chemotherapy is being carefully studied in a clinical trial sponsored by the National Cancer Institute.

Radiation therapy uses high-energy x-rays to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external radiation therapy) or from putting materials that produce radiation (radioisotopes) through thin plastic tubes in the area where the cancer cells are found (internal radiation therapy).

Biological therapy tries to get your body to fight cancer. It uses materials made by your body or made in a laboratory to boost, direct, or restore your body’s natural defenses against disease. Biological therapy is sometimes called biological response modifier (BRM) therapy or immunotherapy. Biological therapy may be given in a fluid that is put into the bladder through a tube going through the urethra (intravesical biological therapy).

Photodynamic therapy is a new type of treatment that uses special drugs and light to kill cancer cells. A drug that makes cancer cells more sensitive to light is put into the bladder, and a special light is used to shine on the bladder. This therapy is being studied for early stages of bladder cancer.

Treatment By Stage

Treatment of cancer of the bladder depends on the stage of your disease, the type of your disease, your age, and your overall condition.

You may receive treatment that is considered standard based on its effectiveness in a number of patients in past studies, or you may choose to go into a clinical trial. Not all patients are cured with standard therapy, and some standard treatments may have more side effects than are desired. For these reasons, clinical trials are designed to find better ways to treat cancer patients and are based on the most up-to-date information. Clinical trials are going on in most parts of the country for most stages of cancer of the bladder. If you want more information, call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237); TTY at 1-800-332-8615.

STAGE 0 BLADDER CANCER

Your treatment may be one of the following: 1. Removal of the cancer using a cystoscope inserted through the urethra to cut out the tumor and burn away any remaining cancer cells (transurethral resection with fulguration). 2. Transurethral resection with fulguration followed by intravesical chemotherapy or biological therapy. 3. Surgery to remove part of the bladder (segmental cystectomy). 4. Intravesical chemotherapy or intravesical biological therapy alone. Clinical trials are evaluating new agents to be given this way. 5. Surgery to remove the whole bladder and organs around it (radical cystectomy). 6. A clinical trial of photodynamic therapy. 7. A clinical trial of intravesical biological therapy. 8. After you have been treated for the cancer, you may be given agents to prevent the cancer from coming back.

STAGE I BLADDER CANCER

Your treatment may be one of the following: 1. Removal of the cancer using a cystoscope inserted through the urethra to cut out the tumor and burn away any remaining cancer cells (transurethral resection with fulguration). 2. Transurethral resection and fulguration followed by intravesical chemotherapy or biological therapy. 3. Intravesical chemotherapy or biological therapy alone. 4. Surgery to remove part of the bladder (segmental cystectomy). 5. Surgery to remove the whole bladder and organs around it (radical cystectomy). 6. Internal radiation therapy with or without external-beam radiation therapy. 7. A clinical trial of agents to prevent the cancer from coming back after you have been treated for cancer. 8. A clinical trial of intravesical therapy.

STAGE II BLADDER CANCER

Your treatment may be one of the following: 1. Surgery to remove the whole bladder and the organs around it (radical cystectomy). The lymph nodes in the pelvis may also be removed (lymph node dissection). 2. External-beam radiation therapy alone. 3. Internal radiation therapy before or after external-beam radiation therapy. 4. Internal radiation therapy alone. 5. Removal of the cancer using a cystoscope inserted through the urethra to cut out the tumor and burn away any remaining cancer cells (transurethral resection with fulguration). 6. Surgery to remove part of the bladder (segmental cystectomy). 7. Clinical trials of systemic chemotherapy before cystectomy (neoadjuvant chemotherapy) or after cystectomy (adjuvant chemotherapy). 8. A clinical trial of systemic chemotherapy plus radiation therapy.

STAGE III BLADDER CANCER

Your treatment may be one of the following: 1. Radical cystectomy. The lymph nodes in the pelvis may also be removed (pelvic lymph node dissection). 2. External radiation therapy. 3. External-beam and internal radiation therapy. 4. Surgery to remove part of the bladder (segmental cystectomy). 5. Internal radiation therapy. 6. External-beam radiation and chemotherapy. 7. A clinical trial of systemic chemotherapy before cystectomy (neoadjuvant chemotherapy) or after cystectomy (adjuvant chemotherapy). 8. A clinical trial of chemotherapy and radiotherapy to allow you to keep your bladder.

STAGE IV BLADDER CANCER

If you have stage IV bladder cancer that has spread to nearby tissue or lymph nodes, but not to other parts of the body, your treatment may be one of the following: 1. Radical cystectomy. 2. External-beam radiation therapy. 3. Surgery to make a way for urine to flow out of the body so that it does not go into the bladder (urinary diversion), to reduce symptoms. 4. Surgery to remove the bladder (cystectomy) to relieve symptoms. 5. Systemic chemotherapy by itself or in addition to surgery. 6. A clinical trial of systemic chemotherapy before cystectomy (neoadjuvant chemotherapy) or after cystectomy (adjuvant chemotherapy). 7. A clinical trial of chemotherapy and radiation therapy to allow you to keep your bladder.

If the cancer is found in lymph nodes or other places far away from the bladder, your treatment may be one of the following: 1. External-beam radiation therapy. 2. Surgery to make a way for urine to pass out of the body without going through the bladder (urinary diversion) to reduce symptoms. 3. Surgery to remove the bladder (cystectomy) and to make a urinary diversion to reduce symptoms. 4. Systemic chemotherapy alone or in addition to surgery. 5. A clinical trial of chemotherapy.

RECURRENT BLADDER CANCER

If your cancer comes back only in the bladder, treatment may be surgery, chemotherapy, or radiation therapy, depending on what treatment you received when you first got your cancer. If your cancer comes back following surgery to remove all of the bladder, you may receive chemotherapy. You may also choose to participate in a clinical trial.

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A risk factor is anything that increases your chance of getting a disease such as cancer. Different cancers have different risk factors. For example, exposing skin to strong sunlight is a risk factor for skin cancer. Smoking is a risk factor for cancers of the lung, mouth, larynx, kidney, and several other organs (including the bladder). But having a risk factor, or even several, does not mean that you will get the disease.

Many people with one or more risk factors never develop bladder cancer, while others with this disease have no known risk factors. It is important, however, to know about risk factors so that appropriate action can be taken such as changing a health behavior or being monitored closely for a potential cancer. Because the bladder is the final exit from the body for many chemicals, these are the major risk factors for bladder cancer.

Smoking

The greatest risk factor for bladder cancer is smoking. Smokers are more than twice as likely to get bladder cancer as nonsmokers. Smoking causes nearly half of the deaths from bladder cancer among men (48%) and less than a third of bladder cancer deaths in women (28%). Some of the carcinogens (cancer-causing chemicals) in tobacco smoke are absorbed from the lungs and get into the blood. From the blood, they are filtered by the kidneys and concentrated in the urine. These chemicals in the urine damage the urothelial cells that line the inside of the bladder. This damage increases the chance of cancer developing.

Occupational Exposures

Certain industrial chemicals have been linked with bladder cancer. Chemicals called aromatic amines, such as benzidine and beta-naphthylamine, which are sometimes used in the dye industry, can cause bladder cancer.

Other industries that use certain organic chemicals also may put workers at risk for bladder cancer if exposure is not limited by good work place safety practices. The industries carrying highest risks include the makers of rubber, leather, textiles, and paint products as well as printing companies. Other workers with an increased risk of developing bladder cancer include painters, hairdressers, machinists, printers and truck drivers (these because of exposure to diesel fumes).

Cigarette smoking and occupational exposures may act together in the development of bladder cancer. Also, smokers who work with the cancer-causing chemicals noted above have an especially high risk of developing bladder cancer.

Race

Whites are about twice as likely to develop bladder cancer compared with African Americans and Hispanics. The reason for this difference is not well understood. Asians have the lowest incidence of bladder cancer.

Increasing Age

The risk of bladder cancer increases with age. Over 70% of people with bladder cancer are older than 65 years old.

Gender

Men get bladder cancer at a rate 4 times greater than women.

Chronic Bladder Inflammation

Urinary infections, kidney and bladder stones, and other causes of chronic bladder irritation have been linked with bladder cancer (especially squamous cell carcinoma of the bladder), but they do not necessarily cause bladder cancer. Schistosomiasis (also known as bilharziasis), an infection with a parasitic worm called Schistosoma hematobium that can get into the bladder, is also a risk factor for bladder cancer. Although this parasite is found mostly in Northern Africa, it does cause rare cases of bladder cancer in the United States among people who had been infected by the worm before moving to this country.

Personal History of Bladder Cancer

Urothelial carcinomas can form in many areas in the bladder as well as in the lining of the kidney, the ureters, and urethra. Even when 1 bladder tumor is completely removed, you will have a higher risk of forming another tumor in the same or another portion of the urothelium. For this reason, people who have had bladder cancer need close, routine medical follow-up. People who have family members who have or have had bladder cancer are at increased risk.

Bladder Birth Defects

Before birth, there is a connection between the belly button and the bladder. This connection, called the urachus, normally disappears before birth. If part of this connection remains after birth, it could become cancerous. Cancers that start in the urachus are usually made up of malignant gland cells and are called adenocarcinomas. Cancer starting in this way is rare, causing less than a half of 1% of bladder cancers. However, it does represent about one third of the adenocarcinomas of the bladder, which are also rare.

There is another rare birth defect called exstrophy, which greatly (about 400-fold) increases a person’s risk of developing bladder cancer. In exstrophy, the skin, muscle, and connective tissue in front of the bladder fail to close completely so that there is a hole or defect in the wall of the abdomen. This leaves the inside of the bladder exposed to chronic infection, which may eventually lead to formation of an adenocarcinoma of the bladder.

Genetics

Bladder cancer has been found to be common in some families. This may account for 1% of all cases. People with a mutation of the retinoblastoma gene, which causes them to develop cancer of their eye as infants, have a higher rate of bladder cancer. Many studies have found that people differ in their ability to break down chemicals in their body and that this is determined by certain genes they inherit. People who inherit genes that lead to slow breakdown of chemicals are more likely to develop bladder cancer.

Chemotherapy and Radiation Therapy

High doses of cyclophosphamide (Cytoxan), a drug used in the treatment of cancer, and ifosfamide (Ifex), a drug similar to cyclophosphamide, increase the risk of bladder cancer. A typical patient would be one with a lymphoma, which is often cured by chemotherapy regimens that include cyclophosphamide. A drug called mesna is used with these 2 drugs to protect the bladder from irritation and decrease the risk of bladder cancer. People who receive radiation treatment to the pelvis are more likely to develop bladder cancer.

Drinking Water and Arsenic

Arsenic in drinking water has been associated with an increased risk of bladder cancer. Risk depends in large part where you live, and whether your water system meets suggested standards for arsenic content.

Fluid consumption

Low fluid consumption increases risk. People who drink a lot of fluids each day have a lower rate of bladder cancer. This is thought to be because they empty their bladders often. By doing this, they keep chemicals from lingering in their bodies.

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The following things affect a person’s chances of developing bladder cancer.

Age

The risk of developing bladder cancer increases with age. Two thirds of all cases occur in people over 70.

Gender

Bladder cancer affects more men than women.

Smoking

Smoking increases the risk of bladder cancer.

Chemicals

Certain chemicals cause bladder cancer. These have been used in the past in the painting and decorating, leather-working, dyeing, papermaking, dry cleaning, rubber and plastic, and mechanics industries. Even though these chemicals have been banned in the UK for decades, they still cause new cases of bladder cancer today because of the long time the cancer takes to develop.

Previous bladder cancer

Having had bladder cancer in the past increases the risk of developing it again.

Bladder stones and repeated infections

Repeated or chronic bladder infections, or bladder stones, slightly increase the risk of developing bladder cancer.

You can find out more about what ‘cancer risk’ means in the ‘Understanding ‘risk’‘ section of this website.

Signs and symptoms

Symptoms of bladder cancer include:

—      blood in the urine

—      experiencing pain when passing urine

—      the need to pass urine very often or very urgently.

None of these symptoms are necessarily due to bladder cancer because infections can also cause these signs. However, anyone noticing these signs should report them to a doctor.

Screening

There is currently no reliable screening test available for bladder cancer.

However, Cancer Research UK is supporting research to develop a urine test based on a protein called MCM5.

Detection

A doctor may carry out the following if he or she doctor thinks you might have bladder cancer:

—      Medical history, urine sample and internal examination
Initially, a doctor will carry out an examination and a urine test. The doctor will also ask about any similar problems in the past, and whether there might have been exposure to certain chemicals at work. They may also want to carry out an internal examination of the rectum (back passage) and, in the case of women, of the vagina. If the doctor detects anything abnormal, a specialist may carry out further tests.

—      Cystoscopy
The specialist may want to examine the inside of the bladder. The procedure is called cystoscopy, and means inserting a tube into the bladder under local or general anaesthetic. The tube has optic fibres inside it that allow the doctor to view the inside of the bladder. The doctor may remove any unusual growth, or take biopsies from the bladder lining to aid diagnosis.

—      Scans
If cancer is present, the specialist will want to find out if it has spread to other parts of the body, and may want to carry out some scans. These might include:

—      a CT scan or MRI scan

—      a bone scan or liver ultrasound scan

—      an X-ray of the bladder (or ‘intravenous urogram’).

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Like many people with cancer, you may choose to take an active role in the decisions affecting your medical care. If so, try to learn as much as you can about bladder cancer and the treatment options that exist. As part of this process, you may want to consider getting a second opinion from a bladder cancer specialist, such as an urologist, medical oncologist or urologic oncologist.

In many cases, your primary care doctor may refer you to one or more specialists. You can also get the names of specialists from a nearby hospital or medical school. Or, contact the Cancer Information Service at (800) 4-CANCER, or (800) 422-6237, to find out information about cancer centers and programs supported by the National Cancer Institute.

Ultimately, the best treatment for you will depend on a number of factors, including the type and extent of bladder cancer you have, as well as on your age, overall health and personal preferences. Below are some of the treatment options:

Surgical procedures

Surgical treatments are usually the best option for people with bladder cancer. The most common procedures include:

—      Transurethral resection (TUR). This is often used to treat superficial bladder cancer. During TUR, your doctor inserts a cystoscope — an instrument with a special lens and fiber-optic lighting system — into your bladder through your urethra. The cancer is removed with a small wire loop and any remaining cells are burned away with an electric current. In some cases, a high-energy laser may be used instead of the electric current. TUR itself causes few problems. You’re likely to have some blood in your urine or pain when you urinate for a few days following the procedure. But because superficial bladder cancer commonly recurs, you’ll need to see your doctor for a cystoscopic exam every three to six months.

—      Segmental cystectomy. This procedure may be an option when a tumor has invaded just one part of the bladder wall. It removes only the portion of the bladder that contains cancer cells. To remove the tumor, the surgeon makes an incision in your abdomen. General anesthesia is used, and you usually stay in the hospital for a week to 10 days. The main side effect of this surgery is more frequent urination. Although the problem is often temporary, it may become permanent in some people.

—      Radical cystectomy. Doctors may use this extensive operation for invasive bladder cancer or for superficial cancer that affects a large portion of the bladder. It involves removing the entire bladder, as well as nearby lymph nodes and part of the urethra. In men, the prostate gland, seminal vesicles — which produce some of the fluid in semen — and a portion of the vas deferens (a conduit for sperm) also are removed. For women, radical cystectomy usually means removing the ovaries, fallopian tubes and part of the vagina.

After a radical cystectomy, your surgeon may construct a new bladder for you or attach a pouch — either internally or externally — to collect urine.

Radical cystectomy can be life altering, affecting not only your ability to urinate normally but also your sexuality. Women who lose their ovaries and fallopian tubes are no longer able to become pregnant and enter menopause immediately. In addition, removing part of the vagina during surgery can affect the ability to have sexual intercourse.

In the past, the vast majority of men became impotent after a radical cystectomy. Now, new surgical procedures may prevent this problem in a very select group of men. Still, removing the prostate gland and seminal vesicles means that semen is no longer produced and sperm aren’t released during ejaculation. Bladder cancer usually occurs in men after the years of active reproduction, but some men who have a cystectomy early in life choose to bank their sperm before surgery. Others may later decide on a procedure in which sperm are removed from their testicles.

Radiation therapy

This therapy uses high-energy X-rays to destroy cancer cells and shrink tumors. It’s most often used after an operation to eliminate any remaining cancer cells. When surgical treatment isn’t an option, radiation may sometimes be used instead, but it’s much less effective than surgery.

In treating bladder cancer, radiation may either come from outside your body (external radiation) or from radioactive materials placed directly into your bladder (internal radiation).

External radiation is usually performed as an outpatient procedure, with treatments occurring five days a week for five to seven weeks.

You may find that you become tired during radiation therapy, especially during the last weeks of treatment. External radiation can also cause your skin to become red, tender and itchy — just as if you had sunburn. Women may also experience vaginal dryness, and men may have problems with impotence. Radiation may also cause bladder or bowel incontinence, impotence in men and irritation of the rectum, leading to diarrhea. These side effects are usually temporary. In the meantime, your doctor may be able to offer measures to make them more manageable.

Chemotherapy

This treatment uses drugs to destroy cancer cells. Your doctor may suggest having chemotherapy after an operation to eliminate any remaining traces of cancer, but sometimes you may have it before a surgical procedure in an effort to spare your bladder.

In most cases, two or more drugs are used in combination. They sometimes may be inserted directly into your bladder through your urethra — a procedure known as intravesical therapy. This treatment is commonly used after TUR to help prevent a very superficial cancer from recurring. You are likely to have intravesical therapy once a week for several weeks.

This isn’t an option if cancer cells have penetrated deep into the bladder wall or spread to other organs. In that case, chemotherapy drugs are given intravenously so that they travel through your bloodstream to every part of your body (systemic chemotherapy). This treatment is given in several cycles, which gives your body a chance to recover between sessions.

Even so, the side effects of chemotherapy — hair loss, nausea, vomiting and fatigue — can be severe. They occur because chemotherapy affects healthy cells — especially fast-growing cells in your digestive tract, hair and bone marrow — as well as cancerous ones. Not everyone has these side effects, however, and there are now better ways to control them if you do.

Systemic chemotherapy may also reduce the number of white and red blood cells in your body, making you temporarily more prone to infections and bruising. In addition, some drugs used to treat bladder cancer may cause kidney damage. To help prevent kidney problems, you may be given intravenous fluids during your treatment and advised to drink lots of fluids.

Biological therapy

Biological therapy stimulates your body’s own immune system to fight cancer. It’s usually used after TUR to help prevent superficial bladder cancer from recurring. Bacille Calmette-Guerin (BCG), a bacterium used in vaccines against tuberculosis, is the most commonly used immune stimulant. It binds to your bladder, where it triggers a response that inhibits the formation and growth of tumors. BCG is administered directly into your bladder using a small, flexible tube (catheter) for two hours once a week. Treatment may last six or more weeks.

During treatment with BCG, you may have some bladder irritation or blood in your urine and feel as if you have the flu. Your doctor may suggest a medication to help reduce some of these signs and symptoms. If you have a persistent high fever — greater than 101.5 F — that doesn’t respond to pain relievers, see your doctor promptly for treatment. This may indicate widespread infection of BCG, which can be serious.

Other treatments

Standard therapies for bladder cancer may not always be effective, or you may not be able to tolerate the side effects. In that case, several other treatments may be an option. One such option is photodynamic therapy (PDT).

This two-part treatment helps destroy bladder cancer cells. Initially you receive an injection of a chemical that is taken up by cancer cells but not by healthy ones. The cells containing the chemical are then exposed to light from a laser, which kills or severely damages them.

PDT may produce serious side effects, such as chronic bladder infections, bladder shrinkage and long-term sensitivity to sunlight. While promising, this therapy is only done at a limited number of centers and needs further study before it can be routinely recommended.

Bladder reconstruction

In radical cystectomy, your bladder is completely removed. Immediately afterward, your surgeon reconstructs your urinary system so that you can eliminate urine effectively. Several options for bladder reconstruction exist. The best approach for you depends on a number of factors, including your overall health and the extent to which the cancer has spread. In all cases, the goal is to maintain your quality of life as much as possible. Some reconstructive procedures include:

—      Urinary conduit. This is the simplest operation with the least risk of complications. It involves isolating a segment of your small intestine and attaching one end of it to your ureters. The other end is connected to an opening (stoma) in your lower abdomen through which urine drains into a small bag. You wear the bag outside your body and empty it three or four times a day. In the evening you can use a larger bag that allows you to sleep through the night.

—      Catheterizable stoma. This type of reconstruction eliminates the need for a bag. Instead, your surgeon fashions an interior pouch capable of holding 3 to 4 cups of urine. You drain the urine from the pouch several times a day using a catheter. Because the size of the pouch remains the same, you must also drain your urine during the night.

—      Neobladder. During this complex reconstructive procedure, your surgeon literally recreates a bladder. This is accomplished by connecting the same type of internal pouch used in a catheterizable stoma to the tube that carries urine from your body (urethra). As a result, you’re able to eliminate urine without having an external opening, although you may need to use a catheter inserted through your urethra. Neobladder reconstruction isn’t an option if some or all of your urethra has been removed, and it may lead to a number of complications, including scarring, internal urine leakage and incontinence.

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The stage of a cancer tells the doctor how far it has spread.  It is important because treatment is often decided according to the stage of a cancer.  There are different ways of staging cancers.  The most common amongst doctors is the TNM system.  This is common to all cancers.  TNM stands for ‘tumour, node, metastasis’.  So this staging system takes into account how deep the tumour has grown into the bladder, whether there is cancer in the lymph nodes and whether the cancer has spread to any other part of the body.  Doctors call cancer spread ‘metastasis’.  The TNM system is a quick and detailed way of writing down the stage of a cancer accurately.  There is more about the TNM cancer stages in our About Cancer section.

Another way of staging cancers is number staging.  This is used for other cancers, but not so much for bladder cancer.  There are usually 4 main stages.  Stage 1 is the earliest cancer and stage 4 the most advanced.  With bladder cancer, it is more usual to refer to early (or superficial) bladder cancer, invasive bladder cancer and advanced bladder cancer.

What is ‘grade’?

You may hear your doctor talk about the ‘grade’ of your cancer. This means how well developed the cell looks like under the microscope.  The more the cancer cell looks like a normal cell, the more it will behave like one

—      The more normal a cancer cell looks, the lower its grade    

—      The more abnormal or less well developed a cancer cell is, the higher its grade

Cancer cells are usually classed as low, medium or high grade.  Other doctors may talk about grades 1, 2, or 3, where G1 is low grade.  A low grade cancer is likely to be less aggressive in its behaviour than a high grade one. Doctors cannot be certain how the cells will behave. But grade is a useful indicator.

If you have early bladder cancer, grade is one thing that your doctor may take into account when deciding your treatment.  If the cells are high grade, you are more likely to need further treatment to stop the cancer coming back after your specialist has removed it.  Carcinoma in situ of the bladder is high grade.

The ‘T’ stages of bladder cancer

The ‘T’ of TNM tells you how far into the bladder the cancer cells have grown

—      CIS - very early cancer cells are detected only in the innermost layer of the bladder lining     

—      Ta - the cancer is just in the innermost layer of the bladder lining     

—      T1 - the cancer has started to grow into the connective tissue beneath the bladder lining     

—      T2- the cancer has grown through the connective tissue into the muscle   

—      T2a - the cancer has grown into the superficial muscle    

—      T2b - the cancer has grown into the deeper muscle     

—      T3 - the cancer has grown through the muscle into the fat layer   

—      T3a - the cancer in the fat layer can only be seen under a microscope (microscopic invasion)    

—      T3b - the cancer in the fat layer can be seen on tests, or felt by the doctor (macroscopic invasion)   

—      T4 - the cancer has spread outside the bladder   

—      T4a - the cancer has spread to the prostate, womb or vagina   

—      T4b - the cancer has spread to the wall of the pelvis and abdomen

The ‘N’ stages of bladder cancer

There are four lymph node stages in bladder cancer.  These relate to lymph nodes in the pelvis (the lower part of your tummy, inside your hip bones, or pelvic girdle).  The stages are

—      N0 - no cancer in any lymph nodes     

—      N1 - one affected lymph node smaller than 2cm across     

—      N2 - one affected lymph node larger than 2cm, but smaller than 5cm. Or more than one node affected, but all of them smaller than 5cm across     

—      N3 - at least one affected lymph node larger than 5cm across

The size of the lymph nodes is used because the more cancer there is growing in a lymph node, the larger it will be.

If you have cancer in lymph nodes, then you have invasive bladder cancer that has begun to spread.  It is also possible for bladder cancer to spread to lymph nodes in the abdomen (above the pelvic area) or to lymph nodes in the neck.

If you have cancer in any lymph nodes, your doctor may want you to have chemotherapy treatment before surgery.  Look at the CancerHelp UK sections on treating invasive bladder cancer and treating advanced bladder cancer for more information.

The ‘M’ stages of bladder cancer

As with most cancers, there are two stages for cancer spread or metastases.  Either the cancer has spread to another body organ (M1) or it hasn’t (M0).  If bladder cancer does spread to another part of the body, it is most likely to go to the bones, lungs or liver.  If your cancer has spread, then you have advanced bladder cancer.  Look at the CancerHelp UK section on treating advanced bladder cancer for more information.

Early bladder cancer and carcinoma in situ

Early bladder cancer is also called ’superficial bladder cancer’.  This includes Ta tumours, T1 tumours and carcinoma in situ (CIS). CIS is called Tis in the bladder cancer TNM staging.

All these are cancers that have been picked up early in their development.  The cancer cells are only in the innermost layer of the bladder - in the lining.  Often, these early bladder tumours look like mushrooms growing out of the bladder wall.  In many cases, these cause no more trouble after your specialist has removed them.

Carcinoma in situ doesn’t stick out from the bladder wall.  It is a cancer of the flat transitional cells that make up all the moist skin-like tissues that line the body organs.  CIS can crop up in more than one place in the bladder lining.

There is a group of early bladder cancers that doctors call ‘high risk’.  They are more likely to come back.  And more likely to go on to develop into a more dangerous invasive bladder cancer.  This group includes carcinoma in situ and T1 tumours.  T1 tumours have started to grow further into the bladder wall than the lining.  The cancer cells have broken through the base of the lining into the supporting tissue underneath.  CIS is ‘high risk’ because the cells are very abnormal.  Doctors call this ‘high grade’.  High grade cancer cells are more likely to grow quickly into the bladder muscle and spread than low grade ones.

If you have ‘high risk’ early bladder cancer, your specialist will want you to have more treatment after removing the cancer.  This will be treatment to the inside of your bladder called intravesical therapy.  This is included in the sectio