Bladder cancer

Diagnosis

Bladder cancer diagnosis often begins with an exam and talking with a healthcare professional about symptoms. A test called cystoscopy may be used to look for anything that's not typical inside the bladder. Urine tests and imaging tests also may be useful. To check for cancer, a sample of tissue may be taken from the bladder for testing. A procedure called transurethral resection of bladder tumor (TURBT) may be used to diagnose and treat bladder cancer at the same time.

Cystoscopy

Cystoscopy is a procedure that lets a healthcare professional see inside the bladder. During cystoscopy, a healthcare professional puts a small, narrow tube, called a cystoscope, through the tube that takes urine from the bladder out of the body, called the urethra. The cystoscope has a lens the healthcare professional uses to see inside the urethra and bladder to check for signs of disease.

Urine cytology

A urine cytology test involves looking at a sample of urine with a microscope. The test looks for cancer cells.

Imaging tests

Imaging tests, such as computerized tomography (CT) urogram or retrograde pyelogram, make pictures that the healthcare team uses to look at the urinary tract for signs of cancer.

• CT urogram. During a CT urogram, a contrast solution is placed into a vein in the hand. The contrast flows into the kidneys, ureters and bladder. X-ray images taken during the test show a detailed view of the urinary tract. Those images help the healthcare team see any areas that might be cancer.
• Retrograde pyelogram. A retrograde pyelogram is an X-ray exam used to get a detailed look at the upper urinary tract. During this test, a thin tube, called a catheter, is placed through the urethra and into the bladder. Contrast solution then is put into the catheter and flows into the kidneys while X-ray images are taken of that area.

Biopsy

A biopsy is a procedure to remove a sample of tissue for testing in a lab. A healthcare professional may get a tissue sample from the bladder during a cystoscopy exam. The healthcare professional may pass a tool through the scope and into the bladder to do a biopsy.

Transurethral resection of bladder tumor

Transurethral resection of bladder tumor (TURBT) is a procedure to diagnose bladder cancer and to remove small cancers from the inside of the bladder. During the procedure, a healthcare professional passes an electric wire loop through a cystoscope and into the bladder. The electric current in the wire is used to cut away or burn away the cancer. Sometimes a high-energy laser may be used instead of the electric wire loop.

Bladder cancer stages

Bladder cancer stages describe how far the cancer has grown and whether it has spread. The stage helps the healthcare team choose the treatments that are most likely to help. Bladder cancer is staged from 0 to 4. A lower number generally means the cancer is limited to the bladder. A higher number means it has grown farther through the bladder wall or spread beyond the bladder.

Bladder cancer grade

Bladder cancers also are classified by grade. A cancer's grade is based on how the cancer cells look under a microscope. Bladder cancer may be low grade or high grade:

• Low-grade bladder cancer. Low-grade bladder cancer has cells that are closer in appearance and organization to typical cells. A low-grade cancer tends to grow more slowly. It is less likely to grow into the muscle wall of the bladder than is a high-grade cancer.
• High-grade bladder cancer. High-grade bladder cancer has cells that don't look at all like typical tissue. A high-grade cancer tends to grow faster than a low-grade cancer. It also may be more likely to grow into the muscle wall of the bladder and spread to other tissues and organs.

Treatment

Treatment for bladder cancer depends on the type, grade and stage of the cancer, along with your overall health and what you prefer. Depending on the situation, treatment options may include surgery, chemotherapy, radiation therapy, immunotherapy and targeted therapy.

Bladder cancer can sometimes be cured. Non-muscle-invasive bladder cancer has not grown into the bladder muscle and often can be managed with treatments directed at the bladder, such as TURBT and medicines placed directly into the bladder. Muscle-invasive bladder cancer has grown into the bladder muscle and generally needs more intensive treatment, such as surgery with systemic chemotherapy or a combination of chemotherapy and radiation therapy. For metastatic bladder cancer, treatment may help slow or shrink the cancer, ease symptoms, and help people live longer.

Bladder cancer surgery

Bladder cancer surgery removes the cancer cells. Sometimes surgery involves removing part or all of the bladder.

Transurethral resection of bladder tumor (TURBT) is a procedure to diagnose bladder cancer and to remove cancers that are within the inner layers of the bladder only. During the procedure, a healthcare professional passes an electric wire loop through a cystoscope and into the bladder. The electric current in the wire is used to cut away or burn away the cancer. Sometimes a high-energy laser may be used instead of the electric wire loop. Because TURBT is done through the urethra, no surgical cuts, called incisions, are needed.

As part of this procedure, medicine may be placed in the bladder. The medicine can kill cancer cells that are left behind and may help prevent bladder cancer from coming back. The medicine is left in the bladder for a certain amount of time, and then it is drained out.

Cystectomy is surgery to remove all or part of the bladder. During a partial cystectomy, a surgeon takes out only the area of the bladder that has the cancer.

During a radical cystectomy, a surgeon takes out all of the bladder and the lymph nodes around it. Radical cystectomy typically also includes removal of the prostate gland and seminal vesicles, or the uterus, ovaries and part of the vagina.

Radical cystectomy can be done through a surgical cut on the lower part of the belly or with a number of small cuts using robotic surgery. During robotic surgery, the surgeon sits at a computer and uses hand controls to move robotic surgical instruments.

Urinary diversion is a procedure to make a new way for urine to leave the body. It's used after radical cystectomy. Options for urinary diversion may include:

• Neobladder reconstruction. This involves using a piece of intestine to make a place for the body to store urine, called a neobladder. The neobladder sits inside the body and is attached to the urethra. With a neobladder, most people can urinate as they typically would. But a small number of people have trouble emptying the neobladder. When that happens, a catheter may be needed from time to time to drain all the urine out of the body.
• Ileal conduit. For this type of urinary diversion, the surgeon makes a tube, called an ileal conduit, using a piece of intestine. The tube runs from the ureters, which drain urine from the kidneys, to the outside of the body. Urine empties into a pouch worn on the belly. The pouch is called an urostomy bag.
• Continent urinary reservoir. For this type of urinary diversion, the surgeon uses a section of intestine to make a small pouch that holds urine inside the body. The urine then is drained several times a day through an opening in the belly.

Some effects of radical cystectomy and urinary diversion can be long-lasting. Treatment may affect urinary control, sexual function, fertility, bowel function and the body's chemical balance. People who have a urinary diversion also need ongoing care for the new way urine leaves the body.

Chemotherapy

Chemotherapy treats cancer with strong medicines. Bladder cancer chemotherapy often uses two or more medicines together.

Chemotherapy medicines can be given:

• Through a vein. Intravenous chemotherapy is given through a vein. It's often used before bladder removal surgery to raise the chances of curing the cancer. Chemotherapy also may be used to kill cancer cells that might be left behind after surgery. Sometimes, chemotherapy may be used with radiation therapy.
• Directly into the bladder. Intravesical chemotherapy is given directly into the bladder. For the procedure, a tube is passed through the urethra into the bladder. Then chemotherapy is placed in the bladder for a set amount of time before it's drained. This type of chemotherapy may be used as the main treatment for bladder cancer when the cancer cells affect only the lining of the bladder and not the deeper muscle tissue.

Chemotherapy medicines used for bladder cancer depend on the situation. Common medicines include cisplatin and gemcitabine. Chemotherapy placed directly into the bladder may include gemcitabine or mitomycin.

Chemotherapy side effects depend on the medicines used. They may include low blood cell counts, infection, mouth sores, hair loss, fatigue and digestive symptoms. Cisplatin also can affect the kidneys, hearing and nerves. Some effects, such as hearing loss or nerve damage, may last after treatment ends.

Radiation therapy

Radiation therapy treats cancer with powerful energy beams. For bladder cancer, radiation therapy typically is delivered from a machine that moves around a person's body, directing the energy beams to specific places on the body.

Sometimes, radiation therapy is used with chemotherapy to treat bladder cancer, such as when surgery isn't an option.

Radiation therapy can cause urinary and bowel side effects. Some effects can develop or continue after treatment ends. In studies of bladder-preserving treatment, severe late urinary and gastrointestinal side effects were uncommon. But radiation can sometimes cause long-term effects.

Immunotherapy

Immunotherapy is medicine that helps the immune system fight cancer. Immunotherapy can be given:

• Directly into the bladder. Intravesical immunotherapy is given directly into the bladder. It may be used after TURBT for small bladder cancers that haven't grown into the bladder's muscle layer. One medicine used in this way is called bacillus Calmette-Guerin (BCG). BCG causes an immune system reaction that directs germ-fighting cells to the bladder.

  BCG is a standard treatment for certain intermediate- and high-risk non-muscle-invasive bladder cancers. Studies show that BCG after TURBT lowers the risk of the cancer coming back. Maintenance BCG can further reduce recurrence and, in some studies, progression or spread.

  BCG commonly causes bladder irritation and flu-like symptoms. These may include painful or frequent urination, blood in the urine, fever, chills, and fatigue. Most side effects can be managed, but BCG can cause more serious complications in some people. The healthcare team may delay or stop BCG when there are severe local or systemic symptoms.

• Through a vein. Intravenous immunotherapy is given through a vein. It helps the immune system fight the cancer cells.

  Intravenous immunotherapy can cause side effects when the activated immune system affects healthy organs. These effects can involve the skin, intestines, liver, lungs or hormone-producing glands. Some hormone-related side effects can be permanent.

Targeted therapy

Targeted therapy uses medicines that target specific features of cancer cells. For advanced bladder cancer, testing for certain gene changes can help determine whether targeted therapy may be an option.

Bladder preservation

Sometimes, people with bladder cancer that has gone into the bladder's muscle layer don't want to have the bladder removed. In that situation, the healthcare team may use a combination of treatments instead. Called trimodality therapy, this approach uses TURBT, chemotherapy and radiation therapy.

First, a surgeon does a TURBT procedure to take out as much of the cancer as possible while keeping bladder function. Then, after the surgery, chemotherapy along with radiation therapy is given. If any cancer remains after trimodality therapy, a radical cystectomy may be needed.

After bladder cancer treatment

Bladder cancer may come back even after successful treatment. Because of this, people with bladder cancer often have follow-up testing after treatment. What tests you'll have and how often you need them depends in part on the type of bladder cancer you had and how it was treated.

Coping and support

Knowing that bladder cancer might come back could make you worried or anxious. But while there's no way to ensure that bladder cancer won't come back, you can take steps to manage the stress. Try these tips:

• Get a schedule of follow-up tests and go to each appointment. When you finish bladder cancer treatment, ask your healthcare professional to give you a schedule of the follow-up tests you need. Before each follow-up exam, you might have some anxiety. You may be concerned that cancer has come back or worry about the exam. But don't let that 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.
• Do what you can to stay healthy. Take care of yourself by eating a healthy diet, including plenty of fruits and vegetables. Physical activity can help too.
• Talk with other bladder cancer survivors. Other people who have gone through treatment for bladder cancer may feel the same way you do. Talking with them might help. For information about support groups in your area, talk with a member of your healthcare team or contact the American Cancer Society. Find support online through Mayo Clinic Connect, a community where you can connect with others for support, practical information and answers to everyday questions.

Preparing for your appointment

Make an appointment with a healthcare professional if you have any symptoms that worry you. You're likely to start by seeing your primary healthcare professional. But you might be referred to a doctor who specializes in treating diseases and conditions of the urinary tract, called a urologist. Sometimes, you may be referred to other specialists, such as a doctor who treats cancer, called an oncologist. Here are some tips to get ready for your appointment.

What you can do

When you make the appointment, ask if there's anything you need to do before your appointment, such as not eating or drinking for a certain amount of time. Make a list of:

• Your symptoms, including any that don't seem related to the reason for your appointment.
• Key personal information, including major stresses, recent life changes and family medical history.
• All medicines, vitamins and other supplements you take, including the doses.
• Questions to ask your healthcare professional.

Take a family member, friend or another trusted person with you, if possible, to help you remember the information you're given.

For bladder cancer, basic questions to ask your healthcare professional include:

• Do I have bladder cancer, or could my symptoms be caused by another condition?
• What tests do I need?
• What is the stage of my cancer?
• What are my treatment options?
• What treatments might cure bladder cancer?
• What are the possible risks of each treatment?
• Should I see a specialist?
• Is there a generic alternative to the medicine you're prescribing?
• Do I need follow-up appointments?
• Are there brochures or other printed material that I can take with me? What websites do you recommend?

Be sure to ask any other questions you may have.

What to expect from your care team

Your healthcare professional is likely to ask you questions, such as:

• When did your symptoms start?
• Are your symptoms always present, or do they come and go?
• How bad are your symptoms?
• What, if anything, makes your symptoms better?
• What, if anything, makes your symptoms worse?